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EECTAL 
ANT)  Al^AL  SUEGEET 


DESCRIPTION  OF  THE   SECRET    METHODS  OF  THE  ITINERANT 

SPECIALISTS. 


EDMUND   ANDREWS,   M.  D.,   LL.D., 

Professor  of  Clinical  Surgery,  Chicago  Medical  College,  Surgeon  to  Mercy  Hospital,  Etc. 


EDWARD    WYLLYS   ANDREWS,  A.  M.,  M.  D., 

Professor  of  Clinical  Surgery,  Chicago  3Ieclical  College,  Surgeon  to  3Iercy  Hospital,  Etc. 


SECOND   EDITION    REVISED  AND  ENLARGED,  WITH  ILLUSTRA- 
TIONS AND  FORMULARY. 


CHICAGO: 
W.  T.  KEENER,  96  Washington  St. 

1889. 


Copyrighted,  1889,  by  W.  T.  Keeneb. 


PEEFACE    TO   THE    SECOND   EDITION. 


The  rapid  sale  of  the  First  Edition  of  this  manual  has 
compelled  the  preparation  of  a  second  much  sooner  than  was 
anticipated.  Advantage  has  been  taken  of  the  opportunity  thns 
given  to  re-write  and  enlarge  almost  every  part  of  the  work,  and 
to  introduce  several  new  chapters  and  an  appendix.  A  few  cuts 
have  also  been  added. 

A  chapter  has  been  introduced  upon  the  Anatomy  of  the 
Rectum,  which,  it  is  thought,  will  aid  the  explanations  found  in 
other  parts  of  the  work.  Works  upon  general  anatomy  do  not 
usually  contain  all  that  is  needful  for  a  comprehension  of  the 
questions  that  have  been  raised  in  rectal  pathology. 

A  chapter  on  Proctitis  and  its  treatment  has  also  been 
inserted,  the  subject  being  one  now  clearly  recognized  as  of 
clinical  importance. 

As  in  the  earlier  edition,  the  chief  emphasis  has  been  put 
upon  the  practical  side  of  the  subject,  and  an  endeavor  has  been 
made  fairly  to  outline  all  the  forms  of  treatment  for  all  affections, 
including  the  secret  methods  of  the  local  and  traveling  ••  Rectal 
Specialists." 

Further  to  make  this  book  a  vade  mecum,  in  the  hands 
of  those  who  must  hurriedly  tur]^l  many  books  in  the  intervals  of 
active  practice,  a  compact  Formulary  has  been  prepared,  which 
contains  in  classified  form  every  prescription  in  the  body  of  the 
work  and  a  considerable  number  of  others.  These  are  all  tried 
remedies  and  many  of  them  have  their  authors'  names  affixed. 

With  this  formulary  for  reference,  the  practitioner  who  has 
once  read  the  book,  can  by  almost  instantaneous  reference  secure 
the  necessary  details  for  the  treatment  of  any  given  case  which 
is  before  him.  These  formulas  have  been  collected  from  a  very 
large  number  of  works  in  various  languages.  Over  fifty  are 
given,  and  these  are  nearly  all  that  can  be  found  in  a  score  or 


iv.  PREFACE   TO   SECOND   EDITION. 

more  of  the  best  modern  treatises,  those  being  omitted,  of  course, 
which  are  practical  repetitions  of  each  other. 

A  chapter  has  also  been  given  to  the  sacculi  Horneri  and 
columns  of  Morgagni  in  order  more  clearly  to  expose  the  ridicu- 
lous pathology  which  some  have  sought  to  connect  with  these 
innocent  structures. 

6  East-Sixteenth  Street,  Chicago,  Jan.  1,  1880. 


PEEFACE  TO  THE  FIEST  EDITION. 


The  itinerant  "Rectal  Specialists"  of  the  Western  States 
have  become  so  nnnierous  that  very  general  notice  has  been 
attracted  to  their  methods,  and  one  good  result,  at  least,  has  been 
brought  about  through  their  influence:  Their  competition  has 
compelled  physicians  to  give  more  attention  to  the  neglected  sub- 
ject of  rectal  diseases.  Hence  has  arisen  an  urgent  call  for  infor- 
mation upon  two  points: 

1.  What  are  the  best  modern  methods  of  diagnosis  and 
treatment  known  to  the  regular  profession? 

2.  What  are  secret  methods  of  the  "  specialists,''  and  what 
their  value? 

To  answer  these  questions  we  have  written  this  book.  We 
have  endeavored  to  condense  into  it  the  results  of  our  own  special 
investigations  and  the  established  o})inions,  unequivocally  stated, 
of  authorities  both  European  and  American.  To  this  we  have 
added,  in  each  department,  the  secret  fornuilas  of  the  irregulars 
which,  for  several  years,  we  have  been  collecting. 

The  evolution  of  the  itinerant  pile  doctor  is  an  amusing  bit 
of  histor}^,  and  here  may  be  given  space  more  properly  than  in 
the  text. 

About  1871,  a  young  and  ingenious  physician  in  Central  Illi- 
nois hit  upon  a  means  of  removing  piles  by  injecting  into  them, 
with  a  hypodermic  syringe,  a  caustic  mixture  of  carbolic  acid  and 
olive  oil.  Having  tested  the  plan  and  found  that  it  often  effected 
perfect  cures  he  abandoned  an  insignificant  local  practice  for  a 
veiy  lucrative  business  as  a  traveling  pile  doctor.  The  method  was 
kept  a  secret,  but  its  fame  extended  and  the  original  inventor  and 
his  partners  were  enabled  to  sell  the  right  to  use  it  for  large  sums 
to  regular  and  irregular  practitioners  in  a  large  number  of  places. 

Many  of  the  itinerants  who  bought  and  used  the  secret  were 


VI.  PREFACE    TO   FIRST  EDITION. 

not  medical  men  at  all,  yet  even  in  their  hands  a  certain  amonnt 
of  success  was  obtained,  and  reputation  of  being  able  to  cure 
piles  "without  pain  or  operation  "  was  fairly  well  sustained. 

Regular  physicians  were  for  a  number  of  years  wholly  at  a  loss 
to  account  for  the  sviccess  which  these  itinerants  obtained.  Our 
own  discovery  of  the  secret  resulted  partly  from  the  indiscretion 
of  a  "  specialist  "  who  exemplified  the  saying  in  vino  Veritas,  and 
partly  from  the  information  obtained  by  a  Chicago  druggist  who. 
furnished  the  same  man  and  others  their  solutions.  We  pub- 
lished the  knowledge  thus  obtained  simultaneously  in  five  promi- 
nent medical  journals,  and  as  a  result  were  shortly  in  receipt  of 
hundreds  of  letters  from  persons  of  all  classes,  with  reports  of 
thousands  of  cases,  and  the  results,  both  good  and  bad,  of  the 
method.  The  sale  of  "  rights  "  ceased  quickly.  In  several  cases 
application  was  made  for  our  testimony  that  the  publication  had 
been  made  at  a  certain  date,  in  order  to  enable  persons  who  had 
been  victimized  to  recover  money  paid  for  what  was  no  longer 
really  a  secret.  The  sums  so  paid  for  exclusive  rights  in  a  lim- 
ited district  were  from  one  thousand  to  fifteen  hundred  dollars. 

The  modern  Western  "  Rectal  Specialist  "  is  lineal  descend- 
ant of  the  original  pile  doctor.  He  uses  still,  in  common  with 
many  reputable  physicians,  the  hypodermic  method  in  treating 
piles,  but  his  evolution  has  proceeded  so  far  that  he  now  under- 
takes to  treat  other  common  rectal  diseases  as  well,  in  a  fashion 
peculiarly  his  own  and  suited  rather  to  his  own  convenience  as  an 
itinerant  than  to  his  patient's  real  welfare.  He  no  longer  buys 
his  secret  and  local  right  to  practice,  but  invests  from  fifty  to  one 
hundred  dollars  in  one  of  the  "systems."  He  thus  obtains  a 
complete  set  of  instruments  and  small  secret  manual  of  instruc- 
tions which  "enable  persons  of  no  particular  skill  to  treat  suc- 
cessfully all  rectal  diseases."  As  a  matter  of  fact  many  of  these 
persons  are  not  medical  graduates  at  all,  but  mere  adventurers 
whose  entire  knowledge  of  their  specialty  consists  in  what  their 
little  book  of  instructions  has  furnished  them.  In  some  instances 
the  itinerant  is  not  allowed  to  know  the  composition  of  the  various 
remedies  directed  by  the  secret  pamphlet.  He  must  buy  them  of 
the  author  of  the  "  system,"  thus  continually  paying  him  tribute. 
Several  of  these  "  systems,"  by  underselling  each  other  have 
greatly  reduced  their  prices,  so  that  from  three  hundred  dollars 


PREFACE    TO    FIRST   EDITION.  Vll. 

they  have  now  fallen  in  price  to  iifty,  or  even  less,  and  are  much 
improved  in  quality. 

The  itinerants  themselves,  moreover,  have  now  enlarged  their 
field  of  operation  and  their  incomes  by  adopting  an  iniquitous 
mass  of  pathological  rubbish  concerning  the  sacciili  Horneri  and 
Morgagni's  columns.  There  are  few  things  more  melancholy 
tha|^  the  weakness  of  afflicted  human  nature  for  all  kinds  of 
quackeiy.  If,  however,  there  are  differences  in  degree  of  charla- 
tanism, that  form  which  invents  imaginaiy  diseases  for  its 
victims  is  surely  more  vicious  than  that  which  only  offers  use- 
less remedies. 

From  what  has  been  said  of  the  general  attainments  of  the 
"Rectal  Specialists"'  it  will  be  seen  that  most  of  them  are  too 
ignorant  to  know  better  when  told  that  the  saccuU  Horneri,  the 
papillcB  and  columns  of  Morgagni  (long  ago  discovered,  and 
studied  by  anatomists  and  rectal  surgeons)  are  signs  of  disease 
hitherto  undescribed.  They  have  a  motive,  too,  in  believing  that 
these  simple  structures  are  lesions,  which  demand  treatment.  A 
new  source  of  revenue,  not  taxed  by  the  author  of  any  system,  has 
been  offered  them  and  they  have  availed  themselves  of  it  with 
eagerness. 

Thus  the  evolution  of  the  pile  doctor  proceeds.  From  know- 
ing originally  but  one  thing  he  has  come  to  a  smattering  of  five 
or  six,  and  is  called  a  "Rectal  Specialist." 

Most  practitioners  have  greatly  neglected  the  study  and 
treatment  of  common  surgical  affections  of  the  rectum  and  anus, 
and  left  an  important  field  vacant  for  the  occupation  of  charla- 
tans and  self-styled  experts.  This  manual  has  been  prepared 
with  a  view  to  furnishing  practical  rather  than  historical  or  theo- 
retical information,  for  which  the  reader  is  referred  to  the  syste- 
matic treatises  such  as  the  works  of  Curling,  Van  Buren,  Esmarch, 
Cripps  and  Ball,  or  special  monographs  like  those  of  Bodenhamer, 
Allingham,  Kelsey,  Smith,  Yount,  and  others. 

6  East-Sixteenth  Street,  Chicago,  Nov.  1,  1887. 


TABLE  OF  CONTENTS. 


CHAPTER  I. 

Anatomy  and  Physiology  of  the  Rectum. 

Page 

Relation  of  parts — The  peritoneal  coat — The  muscular  coat — The 
mucous  coat — The  external  sphincter  muscle — The  skin — The  con- 
nective tissue  — Arteries — Veins — Lymphatics — Nerves 1 

CHAPTER  II. 

Methods  of  Examining  the  Rectum. 

Thoroughness — Preliminary  inquiries — Scheme  of  questions — Light — 
External  inspection — Digital  examination — Aseptic  lubricator — 
Rectal  sounds — Internal  inspection — Speculums — Sets  of  rectal 
instruments 9 

CHAPTER  III.      ■ 

Ha:MOKBHOIDS. 

Historical  account — Causation — Varieties — Palliative  measures — Oper- 
ative treatment — Stretching  sphincter — Operation  of  ligation — 
Preparation  of  patient— Treatment  of  haemorrhage  after  oper- 
ations in  the  rectum — Hyjiodermic  injection  method — Clamp  and 
cautery — Ecraseur — Crushing  operation — Various  cauteries — Ex- 
cision of  internal  piles — Circular  excision,  or  Whitehead's  operation     21 

CHAPTER  IV. 

Pboctitis. 
Causes — Varieties — Symptoms — Treatment 45 

CHAPTER  V. 

Diseases  of  the  Sacculi  Hoknebi. 

Ignorance  and  quackery— Anatomical  history — Horner  and  Morgagni 

— Henry  H.  Smith — Ulcerated  sacculi — Excision  when  diseased.  . .      52 


X.  TABLE   OF  CONTENTS. 

CHAPTER  VI. 

Abscess  and  Sinus  ;  Fistula  in  Ano. 

Page 
Comparative  frequency  of  abscesses — Causes — Treatment — Fistula  in 
ano — Varieties — Symptoms — Treatment  — Hippocratic    method — 
Itinerant   methods 57 

CHAPTER  VII. 

Fissure  of  the  Anus;  Rectal,  Ulcebs. 

Historic  note — Influence  of  French  surgeons— Causes — Hilton's  dia- 
grams— Symptoms — Course  and  prognosis — Operative  treatment 
— Forced  dilatation — Milder  measures — Itinerant  methods — Ulcers 
above  the  anus — Causes — Clinical  history — Diagnosis — Treatment     67 

CHAPTER  VIII. 

Prolapsus. 

Classification — Prolapse  of  mucous  membrane — Prolapse  of  all  the 
coats  —  Treatment  —  Operations  —  Excision  —  Cauterization  — 
Potential  cautery — Itinerant  methods 81 

CHAPTER  IX. 

Polypus  and  other  Innocent  Growths. 

Polypus  —  Treatment  —  Itinerant  method — Warts  and  papillomata — 
Treatment  —  Condylomata  —  Fibrous,  fatty,  and  cartilaginous 
tumors — Cystic  tumors 87 

CHAPTER  X. 

Mechanical  Obstruction. 

Stricture  of  rectum — Causes — Examination — Treatment — Dilatation — 
Divulsion — External  proctotomy — Internal  proctotomy — Lumbar 
Colotomy — Obstruction  from  foreign  bodies — From  benign  tumors 
— From  displaced  organs — From  inflammatory  thickening — Spasm 
of  anus — Impaction  of  fteces 90 

CHAPTER  XI. 

Malignant  Tumors. 

Carcinoma  of  rectum — Causation — Heredity — Climate — Diagnosis — 
Treatment — Mortality — Sarcoma  of  rectum — Colotomy  for  com- 
plete obstruction — Details  of  operation 101 


TABLE    OF   CONTENTS.  XI. 

CHAPTER  XII. 

Malfokmations;  Peukitus  Ani. 

Page 

Imperforate  amis  —  Imperforate  rectum — Operative   relief — Pruritus 

ani — Causes — Treatment — Successful  formulae — Nerve  stretching..   110 

CHAPTER  XIII. 

Mechanical  Injuries. 

Incised  wounds — Treatment — Punctured  and  lacerated  wounds — Gun- 
shot wounds — Precepts 118 

APPENDIX  AND  FORMULARY. 

Specimen  of  "contract"  to  cure  piles  (1)  —For  use  on  fingers  and  instru- 
ments (2-3) — For  proctitis  (4-9) — For  haemorrhoids  (10-21) — For 
hypodermic  injection  of  haemorrhoids  (22-29) — For  fistula  in  ano 
(30-32)— For  fissure  of  anus  (33-36)— For  ulcers  of  rectum  (37-38) 
— For  prolapsus  (39-40) — For  pruritus  ani  (41-52.) 


ILLUSTRATIONS. 


Page 

1.  Section  of  male  Pelvis,          -             -             -             -             -  -        3 

2.  Nerves  of  Anus  and  Rectum,       -----  7 

3.  Electric  Lamp,           -             -             -             -             -             -  -      11 

4.  Aseptic  Vaseline  Holder,              -----  13 

5.  The  Authors'  Rectal  Sound,               -             -             -             -  -      14 

6.  Speculum  with  Slide,       -             -             -             -  '.         -             -  15 

7.  Authors'  Deep  Tubular  Speculum,  -             -             -             -  -      16 

8.  Authors'  Curved  Rectal  Speculum,          -             -             -             -  Ifi 

9.  Authors'  Short  Tubular  Speculum,  -  -  -  -  -  17 
10.  Allingham's  Short  Speculum,  -  -  -  -  -  17 
11."  Van  Buren's  Speculum,          -             -             -             -             -  -      17 

12.  Kelsey's  Speculum,           ------  18 

13.  Allingham's  Four-bladed  Speculum,             -             -             -  -      18 

14.  Internal  and  External  Piles,        -             -             -             -       .      -  23 

15.  Haemorrhoids  with  Polypus,              -             -             -             -  -      24 

16.  External  Pile  formed  by  Thrombus,      -             -             -             -  24 

17.  Vulsellum  Forceps  for  Piles,              -             -             -             -  -      30 

18.  Smith's  Cautery  Clamp.               -----  38 

19.  Authors'  Ecraseur  Forceps.  -             -             -             -             -  -      39 

20.  Smith's  Wire  Cable  Ecraseur,      -----  40 

21.  Notfs  Ecraseur,          -             -             -             -             -             -  -      41 

22.  Sacculi  Horneri  and  Columns  of  Morgagni,      -             -             -  54 

23.  Sim's  Blunt  Hook,      -             -             -             -             -             -  -      56 

24.  Curved  Scissors,  -------  56 

25.  Fistula  Traversed  by  Probe,  -----      (50 

26.  Internal  Incomplete  Fistula.       -    \         -             -             -             -  fiO 

27.  External  Incomplete  Fistula,            -             -             -             -  -      60 

28.  "Horse-shoe "  Fistula  with  Diverticula,              -             -             -  61 

29.  "Royal"  Bistoury.    -------      63 

30.  Diagram  of  Nerve  Supply  of  Anus,        -             -             -             -  68 
81.  Nerve  Trunks  concerned  in  Reflex  Sjiasm,               -             -  -      70 

32.  Fissure  of  Anus  Unfolded,           -----  72 

33.  Concave  Mirror,         -             -             -             -             -             -  -       77 

34.  Prolapse  of  Mucous  Membrane,              -             -             -             -  81 

35.  Prolapse  of  all  the  Coats,      -             -             -             -             -  -      82 

36.  Club-Shaped  Polypus,     ------  87 

37.  Rounded  Polypus.      -------      87 


xiv.  ILLUSTRATIONS. 

Page 

38.     Villous  Polypus,  -------  88 

3!).     Sargent's  Rectal  Dilator,       -             -             -             -             -             -  93 

40.  Cancerous  Stricture  of  Rectum,              -             -             .             -  106 

41.  Imperforate  Anus,      -------  110 

42.  Imperforate  Rectum,       ------  111 

43.  Nerve  Distribution  about  Anus.        -----  117 


EECTAL    AND    AT^AL    SUEGEEY 


CHAPTER    I. 
ANATOMY  AND    PHYSIOLOGY  OF   THE    KECTUM. 

The  rectum  is  that  portion  of  the  great  intestine 
extending  from  the  left  sacro-iliac  synchonch"osis  downward 
to  the  anus.  Its  relations  to  the  other  organs  of  the  pelvis 
are  shown  in  Fig.  1. 

The  anus  is  the  terminal  orifice  of  the  rectum,  including 
the  nerves,  vessels,  muscles  and  integuments  which  constitute 
the  mechanism  of  the  organ.  The  length  of  the  rectum  in 
the  living  state  is  from  six  to  eight  inches,  but  in  post- 
mortem relaxation  it  becomes  greater.  In  the  main  it 
follows  the  curve  of  the  sacrum,  being  sharply  concave  in 
front,  so  that  the  name  rectum  (straight).,  given  by  the 
ancient  anatomists  from  its  straightness  in  the  inferior 
animals,  which  alone  they  dissected,  is  vvholly  false  in  the 
human  anatomy.  At  the  lower  border  of  the  prostate  gland, 
the  anterior  concavity  ceases,  and  the  gut  turns  abruptly 
downward  and  backward,  giving  at  that  point  a  concavity 
behind.  The  upper  part  of  th6  rectum  lies  somewhat  to 
the  left  of  the  median  plane  of  the  pelvis. 

The  interior  of  the  organ  is  almost  smooth,  showing 
only  in  two  or  three  places  any  tendency  to  the  abundant 
formation  of  large  folds  and  pouches  seen  in  the  colon,  yet 
the  few  valve-like  projections  which  exist  are  sufficient  very 
seriously  to  embarrass  the  examination  of  the  viscus  by 
bougies  and  bulb  sounds. 

The  Peritoneal  Coat. — The  peritoneum  nearly  sur- 
rounds the  rectum  at  its  upper  extremity,  but  as  we  trace  it 


2  RECTAL   AND   ANAL   SURGERY. 

downward  it  leaves,  first  the  posterior,  and  then  the  lateral 
surfaces,  and  is  absent  altogether  in  most  cases  from  the 
lower  two  inches.  At  a  somewhat  variable  height,  the  peri- 
toneum is  reflected  upward  in  front,  forming  a  cul-de-sac, 
and  passing  over  the  bladder  in  the  male,  and  the  uterus  in 
the  female.  It  would  be  of  great  importance  in  surgical 
operations  if  there  were  a  fixed  and  invariable  height,  below 
which  the  peritoneal  pouch  never  extended,  but  examination 
of  cadavers  has  so  far  failed  to  fix  this  danger  point,  that 
the  anatomists  contradict  each  other  surprisingly,  as  the 
following  list  of  opinions  as  to  its  height  above  the  anus 
shows : 

Malgaigne,  6  to  8  centimetres  in  males  and  4  to  6  in  females. 
Lisfranc,  4  inches  "       "        "     6  "         " 

Ferguson,      10|        ctm.  "      "       "  15    ctm.  "         " 

Richet,  IOt^o         "  "      "       "  l^T^i)  "     " 

Blondin,  8yV         "  "       "       "     4iV  "     "         " 

Velpeau,  5|^  ctm.  with  bladder  empty  and  8  ctm.  distended. 

Legendre,        "       "        "  "  "        "     "      "  " 

Sappey,  "       "        '^  "■  "        "     "      "  " 

Dupuytren,      7  centimetres. 

Luschka,  5*,  to  8  " 

Hyrtl,  8  " 

Sanson,  11  " 

Quain,  4  inches. 

Gronj,  4  " 

Roberts,  2^ 

These  wide  discrepancies  may  be  partly  due  to  careless 
observation,  but  they  arise  mainly  from  the  great  variations 
found  in  the  cadavers  examined.  In  short,  the  danger  point 
has  no  fixed  level,  and  varies  even  in  the  same  patient  with 
the  fullness  or  emptiness  of  the  bladder,  being  higher  when 
this  viscus  is  full,  and  lower  when  empty. 

The  most  that  can  be  averred  is  this:  In  no  ordinary 
case  will  the  peritoneal  fold  be  found  nearer  to  the  anus  than 
an  inch  and  a  half,  but  as  hernial  elongations  of  the  pouch 
occasionally  exist,  the  surgeon  is  compelled  to  hold  himself 


ANATOMY  AND   PHYSIOLOGY   OF  THE   RECTUM. 


in  readiness  to  meet  both  the  peritoneum  and  small  intes- 
tines at  any  level,  even  below  the  sphincter  (if  he  happens  to 
be  dealing  with  a  prolapse). 

The  Muscular  Coat. — The  three  bands  of  longitudinal 
fibres  pertaining  to  the  colon  become  thickened  as  they 
descend  upon  the  rectum  and  sjjread  out  so  as  to  envelop 
the  whole  organ  in  a  somewhat  uniform  coating.  At  the 
lower  end  however,  certain  fascicles  become  separate  as  they 
approach  the  sphincter,  and 
constitute  the  longitudinal 
ridges  which  are  quite  visible 
in  the  living  state  but  which 
are  scarcely  discernible  in  the 
post-mortem  relaxation.  The 
circular  muscular  fibres  lie 
inside  the  longitudinal  ones, 
and  are  rather  loosely  con- 
nected to  the  latter,  so  that 
they  often  come  down  in  pro- 
lapsus, leaving  the  longitudi- 
nal ones  behind.  As  we  de- 
scend, the  lower  portion  of  the 
cii'cular  fibres  becomes  much 
thicker,  constituting  what  is 
called  the  internal  sphincter. 
Its  lower  border  terminates 
abruptly  at  an  elastic  ring  of 
fibrous  tissue  which  forms  the  verge  of  the  anus.  The 
fibrous  ring  may  often  be  seen  through  the  mucous  mem- 
brane as  a  narrow  and  somewhat  obscure  whitish  circle 
called  "Hilton's  white  line." 

Just  above  the  verge  of  the  anus  some  fascicles  con- 
taining both  muscular  and  fibrous  tissue  project  as  ridges 
under  the  mucous  membrane  and  are  called  the  columns  of 
Morgagni.  In  post-mortem  relaxation  they  are  obscure  and 
spread  out  in  a  reticulated  form,   as  shown  in  the  upper 


Fig.  1. 
Section  of  the  Male  Pelvis  cob- 

BECTED  FEOM  A  FbOZEN  CaDAVEE. 

R.  The  Rectum.  B.  The  Bladder.  K.  K. 
Reflections  of  the  peritoneum  before  and 
behind  a  distended  bladder.  G.  The  Pros- 
tate. U.  The  Urethra.  A.  The  Bulb  of  the 
Urethra.  P.  The  Pubis.  S.  The  Sacrum. 
M.  Rectus  Muscle. 


4  RECTAL   AND   ANAL   SURGERY. 

cut  of  Fig.  22,  but  in  the  living  state  the  action  of  the 
spliincter  compresses  the  bands  laterally,  so  as  to  make  them 
assume  a  perpendicular  position.  They  then  appear  as  short 
longitudinal  ridges  closely  crowded  together,  each  about  a 
centimetre  long,  and  converging  to  an  insertion  into  the 
fibrous  ring  of  the  anal  verge.  They  are  often  described  as 
mere  folds  or  wrinkles  of  the  mucous  membrane,  but  this  is 
an  error.  By  close  inspection  the  delicate  and  translucent 
mucous  membrane  can  be  seen  to  glide  loosely  over  the  more 
substantial  framework  of  the  columns  beneath,  but  conform- 
ing to  their  shape.  The  lower  ends  of  the  ridges  are 
connected  by  delicate  webs  covered  by  mucous  membrane 
and  forming  little  pouches  at  the  lower  ends  of  the  grooves 
between  the  columns.  The  pouches  are  called  the  sacculi 
Horneri,  after  the  celebrated  anatomist  Horner  who  described 
them.  Their  function  is  to  retain  a  reserve  of  mucus  which 
is  pressed  out  by  the  passage  of  the  fecal  mass,  and  lubri- 
cates it  at  the  moment  of  expulsion.  The  sacculi,  like  other 
organs,  are  sometimes  diseased,  and  may  require  surgical 
treatment,  but  they  are  usually  normal  and  healthy  organs. 
Many  of  the  itinerant  "pile  doctors"  traversing  the  country 
claim  that  the  sacculi  are  essentially  and  always  abnormal 
and  diseased  tissues  and  they  make  an  important  part  of 
their  fees  by  slitting  them  down. 

The  Mucous  Coat. — The  mucous  membrane  lining  the 
rectum  has  certain  microscopic  peculiarities  of  interest  to 
the  histologist,  which  it  is  not  necessary  for  our  purpose 
to  give  in  detail.  Suffice  it  to  say  that  its  glandular  struc- 
ture secretes  freely  a  tenacious,  transparent  mucus  having  a 
double  function.  First,  it  is  antiseptic,  and  prevents  the 
putrid  fermentation  of  the  fecal  mass  during  its  stay  in  the 
rectum;  and  secondly,  it  lubricates  the  organ  to  facilitate 
the  act  of  expulsion. 

The  mucous  membrane  just  above  the  verge  of  the  anus 
is  almost  transparent  in  the  healthy  state,  and  so  exceedingly 
extensible  that  it  sinks  into  pouches  before  the  pressure  of 


ANATOMY  AND   PHYSIOLOGY   OF   THE   RECTUM.  0 

the  blunt  hook  like  the  softest  and  thinnest  india  rubber, 
and  unskilled  examiners  deceive  themselves  with  the  idea 
that  they  find  the  sacculi  Horneri  wherever  the  blunt  hook 
happens  to  take  hold.  The  true  sacculi,  however,  exist 
only  at  the  lower  ends  of  the  grooves  between  the  columns 
of  Morgagni. 

Between  the  grooves  there  are  a  few  small  papillae,  often 
very  obscure,  situated  just  above  the  verge,  in  a  position 
analogous  to  the  carunculae  myrtiformes  of  the  vagina. 
Under  each  one  is  situated  a  small  bulb  or  enlargement  of  a 
nerve  twig. 

The  papillae  are  probably  tactile  organs,  which  under 
the  friction  of  the  faecal  mass  in  defecation  provoke  reflex 
contractions  of  the  expulsory  muscles  above.  The  traveling 
pile  doctors  generally  claim  that  they  are  diseased  projec- 
tions, and  must  always  be  snipped  off  with  the  scissors. 

The  External  Sphincter  Muscle. — ^This  organ  is  a 
thin  plane  of  muscular  fibres,  surrounding  the  anus  as  the 
orbicularis  oris  does  the  mouth.  It  is  funnel-shaped,  the 
inner  edge  being  turned  upward  and  attached  to  the  fibrovis 
verge  of  the  anus,  while  the  outer  edge  curves  downward 
and  outward.  The  general  form  is  elliptical,  the  posterior 
extremity  arising  from  the  tip  of  the  coccyx,  and  the  anterior 
being  inserted  into  the  fibrous  raphe  of  the  perineum.  Its 
superficial  fibres  are  rather  closely  related  to  the  skin,  and 
throw  the  latter  into  radiating  folds.  The  two  sphincters 
acting  together  close  the  anus.    \ 

The  Skin. — As  above  stated,  the  skin  of  the  anus  is  very 
closely  connected  with  the  surface  of  the  external  sphincter. 
It  is  studded  with  hairs,  and  lies  in  radiating  folds.  At  the 
line  of  junction  with  the  mucous  membrane  it  is  richly  sup- 
plied with  sensory  nerves,  so  that  it  is  subject  to  excessive 
pain  in  many  diseased  conditions. 

The  Connective  Tissue. — This  is  thin  and  dense  on  the 
external  surface  of  the  external  sphincter.  Deeper  and  sur- 
rounding the  rectum  the  connective  tissue  is  very  loose,  to 


6  RECTAL   AND   ANAL   SURGERY. 

allow  of  the  movements  of  the  rectum,  a  condition  which 
permits  an  extensive  burrowing  of  pus  when  abscesses  form 
there.  This  accounts  for  the  fact  that  anal  fistulas  often 
lead  to  cavities  almost  surrounding  the  rectum. 

Arteries. — The  arteries  of  the  rectum  and  anus  consist 
of  three  pairs,  the  superior  hsemorrhoidal,  which  arise  from 
the  superior  mesenteric,  the  middle  haemorrhoidal,  which 
have  a  variable  origin,  and  the  inferior  hsemorrhoidal,  which 
spring  from  the  internal  pudic.  They  are  all  freely  con- 
nected by  anastomoses.  Those  ramifying  above  the  verge 
of  the  anus  form  an  abundant  network  between  the  mucous 
membrane  and  the  muscular  coat,  and  in  cutting  operations 
in  that  part  are  liable  to  bleed  dangerously,  unless  properly 
secured. 

Veins. — The  veins  constitute  a  complete  network  under 
the  skin  and  mucous  membrane,  extending  the  whole  length 
of  the  organ.  They  inosculate  freely  with  each  other. 
Those  outside  of  the  verge  join  together  to  make  the  external 
hemorrhoidal  veins,  and  terminate  in  the  internal  pudic 
trunks.  Those  in  the  anus  proper  combine  into  the  middle 
hsemorrhoidal  veins,  which  send  their  blood  to  the  internal 
iliac  trunks.  The  superior  hsemorrhoidal  veins  arise  from 
numerous  minute  blood  sacs,  quite  variable  in  size,  but  aver- 
aging about  three-sixteenths  of  an  inch  in  diameter  when 
injected,  which  lie  under  the  mucous  membrane  a  little 
above  the  anus.  Good  anatomists  believe  that  this  is  the 
normal  condition  of  things,  and  that  the  little  blood  sacs  are 
healthy  organs,  and  not  incipient  haemorrhoids.  Their  proper 
function,  if  they  have  any,  is  a  matter  of  conjecture.  Pro- 
ceeding upward  from  these  sacs  between  the  mucous  mem- 
brane and  the  muscular  coat  of  the  rectum,  the  superior 
hsemorrhoidals  at  about  three  inches  above  the  verge  pass 
through  certain  foramina,  or  "button-holes,"  to  gain  the 
connective  tissue  outside  the  rectum,  and  thence  proceed  to 
join  the  portal  circulation  on  its  way  to  the  liver.  Verneuil, 
of  Paris,  believes  that  the  contraction  of  these  "  muscular 


ANATOMY  AND   PHYSIOLOGY   OF   THE   RECTUM. 


button-holes "  often  obstructs  the  superior  haeinorrhoidal 
veins,  causing  distention  of  the  little  blood  sacs  near  the 
anus,  and  thus  originating  piles.  The  older  pathologists 
have  generally  believed  that  the  true  seat  of  obstruction  is 
in  the  capillory  circulation  of  the  liver  itself.  Each  of  the 
blood  sacs  sends  a  small  anastomotic  twig  through  the 
sphincter  to  join  the  external  hemorrhoidal  plexus,  thus 
making  a  regular  anastomotic  connection  between  the  portal 
and  the  general  systems  of  veins. 

Lymphatics. — The  lymphatic  trunks  of  the  more  ex- 
ternal parts  converge  to  the  glands  in  the  groin,  while  those 
higher  up  join  the  glands  of  the  pelvic  and  abdominal 
groups,  hence  cancers  and  chancres  of  the  anus  infect  the 
inguinal  glands. 

Nerves. 
— The  rectum 
and  anus  are 
copiously 
supplied  with 
nerves,  both 
from  the  sym- 
pathetic and 
the  spinal  sys- 
tems. The 
spinal  supply 
predominates 
up  to  a  little 
above  the 
verge  of  the 
anus,  but  as 
we  trace  the 
rectum  up- 
ward we  find 
the    spinal 

twigs  gradually  giving  way  to  those  of  sympathetic  origin, 
so  that  at  three  inches  above  the  anus  the  sense  of  touch  in 


Fig.  2. — Nekves  or  Anus  and  Rectum. 
1.  Sacral  Nerves:  posterior  root  di.^tributed  to  coccyx  and  ext. 
sphincter.  2.  Anterior  Root,  to  ext.  sphincter.  3.  Pudic  Nerve 
and  its  branch  the  inferior  hfemorrhoidal.  t.  Tub.  ischii.  s. 
Sacrum,  c.  Sacrum,  sp.  Ext.  sphincter.  /.  Levator  ani.  p. 
Transversus  perinei.     ri.  Ischio-rectal  space. 


b  RECTAL   AND   ANAL   SURGERY. 

the  healthy  organ  is  almost  absent,  while  at  the  verge  itself 
we  have  one  of  the  most  acutely  sensitive  surfaces  of  the 
body.  The  spinal  trunks  come  mainly  from  the  sacral 
plexus.  Owing  to  the  complicated  supply  from  both  sys- 
tems, the  reflexes  of  the  rectvim  and  anus  are  exceedingly 
numerous  and  energetic,  causing  frequent  perplexity  and 
some  mistakes  in  diseased  conditions  as  to  the  real  seat  of 
the  patient's  malady. 


CHAPTER   II. 


METHODS    OF    EXAMINING    THE    KECTUM. 


Like  all  other  diseases  depending  for  their  diagnosis 
upon  skill  and  accuracy  in  physical  examinations,  rectal 
troubles  are  the  source  of  endless  blunders  and  failures  on 
the  part  of  those  who  are  content  with  half  measures,  or 
who  let  mere  inference  take  the  place  of  that  persistent 
study  which  is  due  each  individual  case. 

The  false  method  is  that  of  the  bungler  and  amateur 
who  is  only  right  by  hap-hazard;  the  true  one  is  that  of  the 
professional  expert  who  cannot  be  balked  by  petty  obstacles, 
but  who  will  reach  success  where  others  have  failed,  not  less 
by  his  dogged  persistence  and  thoroughness  than  by  his 
superior  knowledge. 

Preliminary  Inquiries. — The  patient's  own  account  of 
his  ailment  forms  the  most  convenient  introduction  to  the 
investigation  of  most  cases. 

Despite  the  very  erroneous  liotion  which  many  patients 
have  of  the  true  nature  of  their  disease,  this  will  often 
throw  a  flood  of  light  upon  the  case  at  once,  and,  to  the 
mind  of  the  surgeon,  render  farther  examination  almost 
superfluous. 

It  is  best,  however,  to  take  nothing  for  granted,  but  to 
proceed  systematically  even  in  the  simplest  cases,  with  a 
definite  line  of  inquiries,  as  suggested  by  Allingham,  so  that 
no  important  symptom  can  escape  notice. 

9 


10  RECTAL   AND   ANAL   SURGERY. 

No  better  scheme  of  questions  lias  been  devised  than 
the  following: 

1.  Is  there  pain? 

Kind  of  pain — sharp,  lancinating,  burning,  pulsat- 
ing, gnawing,  dull,  paroxysmal,  persistent,  local, 
reflex. 

Is  it  connected  with  the  act  of  expulsion  (tenesmus)  ? 

Is  it  felt  ((.fter  defecation  ? 

Is  it  relieved  by  defecation? 

What  is  its  duration? 

Is  it  relieved  at  times? 

2.  What  of  the  functional  activity  of  the  bowels? 

Is  there  costiveness,  or  the  reverse? 

Is  there  stomach,  intestinal  or  liver  complaint? 

Are  the  stools  normal  in  color? 

In  consistence?     In  shape?     In  odor? 

3.  Is  there  a  discharge  from  the  rectum? 

Is  it  mucous?     Purulent?     Bloody? 
Is  the  hemorrhage  abundant? 
Is  the  blood  fresh  or  coagulated? 
Does  it  come  during  or  after  movements? 

4.  Is  there  during  defecation  or  at  any  time  a  protrusion 

of  the  membranes? 
Does  this  return  spontaneously? 
Can  it  be  made  to  return  ? 
Is  this  painful,  itching,  or  bleeding? 

5.  Is  there  incontinence  of  fseces  or  urine? 

6.  Is  there  a  history  of  tuberculosis?     Syphilis? 

7.  What  has  been  the  patient's  mode  of   life — active — 

sedentary — temperate — eh'.? 

The  answers  to  these  questions  determine  to  some 
extent  the  direction  of  the  phusical  examination,  which  is 
next  in  order,  and  which  must  modify  or  confirm  the  conclu- 
sions toward  which  the  general  symptoms  point. 

Position. — For  operations  and  examinations  requiring 
very    complete    access    to  the    interior   of   the   rectum    the 


METHODS   OF  EXAMINING    THE   RECTUM. 


11 


lithotomy  position  is  the  most  satisfactory.  A  gynaecological 
chair  is  more  convenient  than  a  table  for  this  purpose.  The 
knee-chest  position  upon  a  lounge  or  table  offers  certain 
advantages  for  inspecting  the  deeper  portions  of  the  rectum 
which  cannot  be  obtained  in  any  other  manner.  The  light- 
ing is  also  excellent  in  this  posture,  l)ut  the 
use  of  an  an8esthetic  of  course  is  not  possible. 

For  most  cases  the  Sim's  position  Avill  be 
found  most  suitable,  both  in  examining  and 
operating.  This  is  especially  true  in  hemor- 
rhoids, fissure,  prolapse  and  such  troubles  as 
do  not  require  deep  exploration. 

Light. — Abundant  daylight  should  be  had 
from  an  undraped  window,  or  a  powerful  arti- 
ficial light  such  as  an  argand  burner  or  oil 
reading  lamp  placed  on  a  stand  in  close  prox- 
imity to  the  parts  being  examined.  The  tub- 
ular rectal  specula  require  rather  more  light 
than  those  used  in  the  vagina.  About  the  same 
conditions  are  found  here  as  in  the  use  of  the 
laryngoscope,  and  a  similar  condenser  and 
hooded  lamp  are  very  useful.  Darkening  the 
room  also  assists  very  materially  in  their  use. 
The  best  portable  illuminator  to  be  carried  to 
all  sorts  of  localities  and  residences  is  a  coil  of 
magnesian  wire.  This,  when  held  in  the  fiame 
of  an  oil  lamp  or  a  gas  jet  (a  spirit  lamp  is 
better),  gives  a  magnificent  white  light  almost 
equal  to  direct  sunshine  in  its  Ijlinding  splendor. 
The  beam  may  be  reflected  into  the  speculum  by  j-j^.,  3 
a  plain  or  concave  mirror,  or  thrown  obliquely  Electbic  Lamp. 
past  the  surgeon's  shoulder  directly  into  the  opening.  A 
plate  or  basin  should  be  under  the  light  to  prevent  the 
red-hot  particles  of  magnesia  from  injuring  the  carpet  or 
the  bedding  as  they  fall.  A  calcium  light  of  course  would 
be  excellent,  if  one  should  happen  to  be  accessible  at  the 


12  RECTAL   AND   ANAL  SURGERY. 

place  needed,  but  this  could  almost  never  be  expected.  In 
no  class  of  work  are  the  small  incandescent  electric  lamps  so 
useful  as  in  examinations  about  the  rectum.  These  can  be 
held  in  the  hand,  find  thrust  into  the  deeper  parts  of  the  cavity, 
furnishing  a  powerful  illumination  which  no  reflector  can  give. 

Small  electric  lamps  of  about  one-half  or  one  candle 
power  are  now  furnished,  for  the  use  of  surgeons  and  dent- 
ists. They  are  from  the  size  of  a  pea  upward  and  are 
usually  mounted  upon  slender  handles  provided  with  a  key 
for  closing  the  circuit.  From  six  to  twelve  Le  Clanche  cells 
costing  about  a  dollar  apiece  furnish  a  battery  which  will 
operate  such  a  lamp  intermittently  for  a  year  without  any 
attention. 

External  Inspection. — The  first  step  in  the  physical 
examination  for  supposed  rectal  disease  is  a  thorough  inspec- 
tion of  the  external  parts.  The  most  important  signs  of  the 
presence  of  several  common  diseases  are  here  visible. 

Swelling,  redness  or  tenderness  should  be  carefully 
looked  for  in  the  tissues  surrounding  the  anus,  and  the 
existence  especially  of  any  fistulous  outlet  determined  at 
once. 

The  protrusion  of  hemorrhoids  or  prolapsus  will  also  be 
noted.  Hemorrhoids,  usually,  are  not  externally  visible 
until  forcibly  extruded  by  an  act  similar  to  that  of  defecation. 
Many  patients  can  do  this  at  will,  while  in  others  the  tumors 
cannot  be  determined  by  external  inspection.  External 
inspection  will  also  show  the  presence  of  any  redness, 
excoriation  or  ulceration  of  the  parts  about  the  anus  or  of 
discharges  from  the  rectum.  Fissure  of  the  anus  will  often 
show  a  distinct  sign  of  its  presence  by  a  little  "  sentinel 
pile  "  immediately  below  tbe  fissure. 

Other  troubles  such  as  ulceration  and  stricture  of  the 
rectum,  or  cancerous  tumors  above  the  anus  require  different 
modes  of  examination.  In  the  progress  of  cancer  of  the 
rectum,  the  inguinal  glands  become  enlarged  before  the 
tumor  has  attained  a  large  growth. 


METHODS    OF  EXAMINING    THE   RECTUM. 


13 


Digital  examination  supplements  the  external  inspec- 
tion in  certain  cases  and  is  in  some  respects  more  to  be 
depended  upon  than  internal  inspection.  For  the  detection 
of  enlargement  of  the  prostate,  in  strictures  low  down,  and 
in  testing  the  irritability  of  the  sphincter,  the  finger  is 
superior  to  all  other  instruments.  The  nail  being  made 
short  and  smooth,  the  finger  is  well  lubricated,  and  gently 
insinuated  through  the  orifice.  Most  surgeons  prefer  the 
index  finger  on  account  of  its  superior  delicacy,  but  others 
like  the  middle  digit,  because  of  its  greater  length,  though 
the  superiority  in  length  is  more  than  lost  by  the  interfer- 
ence of  the  adjacent  knuckles.  In  using  the  index,  the 
deepest  touch  is  effected  by  putting  the  radial  side  of 
the  hand  toward  the  perineum,  and  letting  the  three  unused 
fingers  extend  backward  behind  the  sacrum;  but  in  examin- 
ing the  prostate  the  middle  finger  is  best  with  the  palmer 
sui'face  turned  towards  the  pubis. 

It  is  safer  for  the  examiner  to  have  the  finger  well 
anointed  with  some  unguent  which  is  both 
protective  and  antiseptic.  Too  much  care 
cannot  be  exercised  against  poisoning  the 
finger,  as  chancroidal  and  syphilitic  ulcera- 
tions are  not  uncommon  in  and  about  the 
rectum.  An  incautious  exposure  of  an 
abraded  finger,  or  a  "  hang-nail,"  may  give 
rise  to  very  serious  infection.  Vaseline  con- 
taining ten  per  cent,  of  boric  acid,  or  five 
per  cent,  of  carbolic  acid,  is  useful  for  apply- 
ing to  the  fingers  and  instruments.  The 
latter  causes  a  little  temporary  smarting 
when  used  freely  upon  the  anal  mucous 
membrane. 

To  guard  against  possible  infection  of  ^^'^^'^^  Holdeb. 
one  patient  from  another  it  is  well,  in  addition  to  the  ordi- 
nary disinfection  of  hands  and  instruments,  to  keep  the 
lubricant  in   collapsible  tubes,   which   allow  the   escape  of 


Fig.  4. — Aseptic 


14 


RECTAL   AND   ANAL   SURGERY. 


sucli  small  (|UJiiitities  as  are  needed  from  time  to  time 
without  risk  of  infecting  the  remainder. 

When  the  lubricated  finger-tip  is  pressed  gently  into 
the  anus  the  resistance  noticed  will  mark  the  amount  of 
reflex  irritability  of  the  sphincters.  In  the  normal  anus  this 
is  slight,  and  will  be  felt  only  as  feeble  contraction,  which  is 
soon  overcome.  In  diseased  conditions  the  spasmodic  resist- 
ance is  sometimes  very  decided,  and  the  introduction  becomes 
painful  and  difficult.  The  state  of  the  sphincter  is  an  im- 
portant part  of  the  examination,  and  should  always  be  noted. 
Within  the  sphincter  the  finger  finds  the  rectal  walls  in 
the  normal  state,  smooth,  elastic  and  distensible.  The  exist- 
ence of  stricture  low  down,  of  cancerous  induration,  or  of 
inflammatory  exudates,  or  oedema,  can  thus  be  determined. 
The  finger  Avhich  has  become  educated  will  readily  detect 
any  decided  departure  from  the  normal  size  in  the  prostate, 
and  this  should  be  noted  carefully,  as  there  occasionally 
seems  to  be  an  interdependence  of  bladder  irritability  and 
rectal  disease. 

As  a  further  extension  of  examination  by  the  sense  of 
touch,  recourse  must  be  had  to  rectal  sounds  for  the  purpose 
of  detecting  obstructions  in  the  deeper  parts  of  the  rectum. 
The  author's  sound  consists  of  a  hollow 
steel  staff  of  a  curve  taken  from  repeated 
examinations  on  the  cadaver,  and  oval  bulbs 
of  graded  sizes,  from  1  cm.  to  4  cm.  in  dia- 
meter, which  can  be  screwed  upon  it.  This 
instrument  is  used  for  diagnosis  only.     Its 

curve  has  prov- 
ed so  correct 
that  it  can 
readily  pass 

the  sigmoid  flexure,  and  be  felt  through  the  abdominal 
wall  without  serious  inconvenience  to  the  patient.  The 
handle,  staff  and  bulbs  are  perforated  for  convenience  in 
injecting  through  them. 


'Al 


Fig.  5. — The  Author's  Rectal  Sound. 


METHODS    OF  EXAMINING    THE   RECTUM.  15 

Sounds  must  be  used  with  great  gentleness,  as  ulcerated 
spots  in  the  intestine  are  sometimes  exceedingly  thin  and 
may  be  ruptured.  The  easy  passage  of  a  large  bulb  proves 
the  absence  of  stricture  as  far  as  it  goes,  biit  its  arrest  does 
not  prove  the  existence  of  one.  The  ujiper  rectum  and  lower 
colon  have  not  only  plications  of  membrane  projecting  into 
them,  but  the  walls  of  the  gut  are  liable  to  fold  up  over  the 
end  of  an  instrument,  so  that  in  deep  sounding  a  mere  arrest 
of  progress  does  not  prove  the  stricture. 

Tlie  hand  is  sometimes  introduced  into  the  rectum  for 
deep  exploration.  The  operation,  however,  has  sometimes 
caused  death,  and  should  only  be  resorted  to  when  the 
emergency  is  such  as  justifies  incurring  some  risk.  The 
hand  to  be  introduced  should  be  small  in  circumference,  well 
lubricated,  and  introduced  very  slowly  and  carefully,  with 
the  fingers  gathered  into  the  form  of  a  cone.  Of  all  explor- 
atory instruments,  the  index  finger  is  the  one  most  frequently 
called  for,  but  probes  are  necessary  to  trace  fistulfe,  and  a 
grooved  needle,  an  aspirator  or  a  hypodermic  syringe,  may 
be  wanted  to  detect  abscesses. 

Internal  Inspection. — Speculums  for  the  rectum  have 
been  multiplied  until  nearly  every  surgeon  who  has  written 
upon  rectal  diseases,  and  many  an  ambitious  "  specialist"  of 
provincial  fame  has  invented  one  of  his  own  to  bear  his 
name.  The  sharpers  of  the  so-called  "systems,"  which  have 
had  considerable  patronage  among  the  more-  gullible  and 
poorly-qualified  members  of  the  codman  &  shurtleff, 

.  BOSTON.  __— — -r;^^^ 

profession,  have  each  some  cheap    ^^——:^^^^^^g^StStt% 
form  of  ironmongery  which  is  a   ^fniiiffjiiiiiri  iiijpi. iiliiijjiij|M__ 
more  or  less  successful  imitation   fig..;.-8pkcui.umc..  Kkmuvable 
of  a  standard  form  of  speculum.  Slide  Type. 

All  of  these  instruments  are  copies  of  a  few  distinct 
types. 

The  simplest  type  is  perhaps  that  of  the  straight  tube. 
Tubular  specula  were  very  early  employed  for  the  rectum 
and   were    made    both    cylindrical,   conical    and    sometimes 


16 


RECTAL   AND   ANAL   SURGERY. 


fenestrated.  For  examining  the  deep  parts  of  the  rectum 
a  speculum  in  the  form  of  a  cylindrical  tube,  inserted  by 
aid  of  a  plug,  is  the  best. 

The  author's  tubular  speculum  is  made  in  three  sizes. 
The  tube  is  five  inches  in  length  and  made  of  thin  polished 

metal,  and  the 
plug  is  of  pol- 
ished hard  rub- 
ber. The  light 
is  thrown  in  by  a 
concave  mirror, 
and  the  membrane  easily  inspected  in  every  part  as  it  pro- 
lapses over  the  end  of  the  tube  during  its  withdrawal.  If  it 
is  desired  to  inspect  still  deeper,  we  use  a  tube  curved  at  its 
inner  part.  This  being  inserted  follows  the  curve  of  the 
rectum,  and  the  membrane  prolapsing  over  the  end  is  viewed 
by  an  oval  mirror  inserted  on  a  staff,  giving  an  inverted  view, 
like  the  laryngoscope.  The  mirror  is  concave  and  gives  a 
magnified  view  of  the  parts.     The  plan  is  modified  from  one 


Fig.  7. — Authob's  Deep  Tubulae  Speculum. 


Fig.  8. — Authoe's  Cukved  Rectal  Speculum. 

devised  many  years  ago  by  Bodenhamer.  This  enables  one 
to  get  a  very  deep  view  of  the  rectal  walls.  Still  nine-tenths 
of  practical  rectal  surgery  lies  within  two  inches  of  the  verge 
of  the  anus,  and  the  deeper  instruments  do  not  coine  to  very 
frequent  use. 

When  a  critical  inspection  of  every  point  on  the  rectal 


METHODS   OF  EXAMINING    THE   RECTUM. 


17 


Fig.  9. 
Author's  Shoet  Tubulab  Speculum. 


walls  is  desired,  there  is  nothing  equal  to  a  full-sized  tubular 
speculum,  even  for  parts  near  the  outlet.  We  use  a  short 
one  for  that  location,  on  account  of  the  illumination  being 
better,  and  the  fact  that  with 
a  short  tube  the  membrane 
closing  over  the  end  can  be 
\dewed  at  widely  varied  angles. 
It  must  be  borne  in  mind  that 
nine-tenths  of  the  lesions  to 
be  examined  lie  within  an  inch 
of  the  orifice,  and  hence  the 
speculum  oftenest  used  must 
show  the  latter,  even  if  it  fail 
on  the  deeper  parts.  Practically  one  needs  at  least  two 
kinds,  one  short  one  to  show  the  lower  walls  of  the  rectum 
either  through  the  end  or  through 
lateral  openings,  and  the  other 
much  longer  and  open  only  at 
the  end,  for  the  exploration  of 
the  remoter  portions  of  the  viscus. 
The  long  instrument  is  inserted 
deeply  and  then  slowly  withdrawn,  showing  successively 
every  part  of  the  membrane  as  it  prolapses  over  the 
open  extrem- 
ity. Of  the 
short  instru- 
ments, one  of 
the  best  is 
that  of  All- 
ingham.  It 
consists  of  a 
thin,  metal- 
lic, trumpet- 
shaped  shell,  fitting  closely  to  an  ebony  removable  plug  or 
core,  which  projects  beyond  the  tip  to  facilitate  insertion. 
A  fenestrum  or  slot  extends  the  whole  length.     The  instru- 


DMAN   &  SHURTLEFF, 
BOSTON. 

Fig.  10. 

Allingham's  Speculum. 


Fig.  11. — Van  Buben's  Speculum. 


18 


RECTAL   AND   ANAL   SURGERY. 


Fig.  12. — Kelsey's  Speculum. 


ment  is  inserted  with  the  plug  in,  and  the  fenestrum  on 
whatever  side  it  is  desired  first  to  examine.  The  plug 
is  then  withdrawn  and  the  membrane  inspected;  the  plug 

is  then  re-inserted 
and  the  fenestrum 
turned  in  a  new 
direction,  when  the 
plug  is  again  with- 
drawn. The  plug 
prevents  the  edges 
of  the  fenestrum 
from  scraping  the 
membranes  pain- 
fully, and  by  several 
re-insertions  of  it 
the  opening  can  be 
turned  to  every  part 
of  the  rectal  walls.  The  inner  opening  shows  something  of 
the  membrane  prolapsed  over  it,  but  the  orifice  of  the  tip  is 
too  small,  and  the  instrument  too  short  for  efficiency  in  deep 

explorations. 
The  present  rec- 
tal itinerants 
generally  use  a 
small,  tapering 
speculum,  open 
at  the  tip,  and 
having  a  plug 
to  facilitate  en- 
trance. Like 
Allingham's,  it 
is  too  short  and 
too  small  for 
deep  work,  but  as  it  has  a  lateral  fenestrum,  closed  by  a 
removable  slide,  most  of  the  objects  sought  by  that  ignorant 
class  can  be  brought  into  \aew  by  means  of  it. 


Fig.  13. — Allingham's  Foub-bladed  Speculum. 


METHODS    OF  EXAJIINING    THE   RECTUM.  19 

Tubular  specula,  however,  are  solely  for  examination. 
One  cannot  use  them  in  operating.  A  pair  of  Sims'  specula 
set  in  handles  is  very  convenient  in  many  cases  both  for 
examination  and  for  operations. 

Dr.  Kelsey,  of  New  York,  has  devised  a  good  bivalve 
speculum,  which  is,  however,  not  equal  for  general  use  to 
the  four-bladed  speculum  of  AUingham. 

Sets  of  Instruments  for  Rectal  Surgery. — The  diminu- 
tive cases  of  instruments  sold  at  extravagant  prices  to  itin- 
erants and  some  unwary  physicians  are  an  illustration  of  the 
adage  "  knowledge  is  power,"  since  the  possession  of  so  very 
little  knowledge  on  the  part  of  an  ignorant  vender  enables 
him  to  extract  one  hundred  dollars  from  the  j^ocket  of  his 
still  more  ignorant  patron  for  ten  or  fifteen  dollars'  worth  of 
very  simple  appliances.  Of  late  competition  has  brought 
down  the  prices  of  these  sets  somewhat  and  improved  their 
quality.  Chicago  parties  advertise  outfits  at  from  thirty  to 
fifty  dollars,  which  are  not  different  from  those  which  at  first 
found  a  market  at  double  those  figures.  Nevertheless  the 
price  charged  is  exorbitant,  and  the  selection  is  meagre  and 
wholly  insufficient  for  any  surgeon  who  wishes  to  treat  all 
rectal  diseases. 

If  a  physician  wishes,  he  can  provide  himself  with  a  far 
better  outfit  at  a  much  cheaper  rate  by  ordering  from  any 
first-class  instrument  store  one  of  the  following  sets: 

SMALL  RECTAL  CASE. 

1  Allingham's  rectal  speculum.  ^ 

1  Scalpel. 

1  Curved,  sharp-pointed  bistoury. 

1  Curved,  blunt-pointed  bistoury. 

1  Straight  scissors. 

1  Grooved  director. 

1  Silver  probe. 

1  Porte- causti  que. 

1  Small  vulsellum  pile  forceps. 

6  Curved  needles  (assorted  sizes). 


20  RECTAL   AND   ANAL  SURGERY. 

1  Tait's  lock  artery  forceps. 
1  Spool  heavy  ligature  silk. 

LARGE  RECTAL  CASE. 

1   Allingliam's  rectal  speculum. 

1  Andrews'  tubular  rectal  speculum. 

2  Van  Buren's  specula. 
1  Scalpel. 

1  Curved,  sharp-pointed  bistoury. 

1  Curved,  blunt-pointed  bistoury. 

1  Straight  scissors. 

1  Small  vulsellum  pile  forceps. 

4  Tait's  lock  artery  forceps. 

1  Grooved  director. 

1  Silver  probe. 

1   Porte -caustique. 

1  Double  tenaculum. 

1  Large  laryngoscopic  mirror. 

^  Ounce  magnesian  wire  for  illumination-. 

1  Small  spirit  lamp. 

6  Curved  needles  (assorted  sizes). 

1  Smith's  clamp  and  cautery  irons. 

1  Hypodermic  syringe. 

1  Spool  heavy  white  silk. 

1  Hard  rubber  clyster  syringe. 

1  Curved  rectal  sound  with  six  bulbs. 

The  small  case  will  be  furnished  by  most  Chicago  instru- 
ment dealers  for  about  sixteen  dollars,  and  the  large  one  for 
about  fifty  dollars.  If  fewer  or  more  instruments  are 
required,  the  price  will  be  lower  or  higher,  in  proportion. 
Even  the  smaller  case  is  much  better  than  those  possessed 
by  the  itinerants. 


CHAPTER   III. 
HJEMOREHOIDS,  OR  PILES. 

Haemorrhoids,  in  the  strictest  sense,  are  varicose  haemor- 
rhoidal  veins.  However,  the  term  as  used  in  popular  language 
has  been  loosely  extended  to  include  almost  every  small 
tumor  about  the  anus,  whether  of  varicose  origin  or  not. 
Some  centuries  ago  they  were  called  "Emerods,"  and  the 
disease  appears  under  that  name  in  King  James'  version  o£ 
the  Old  Testament,  where  the  Philistines  are  said  to  have 
been  smitten  with  emerods,  and  to  have  made  golden  models 
of  them  as  expiatory  offerings. 

jEtiology. — This  disease  has  its  origin  in  the  fact  that 
when  the  patient  strains  in  defecation,  the  mucous  membrane 
is  more  or  less  everted,  and  in  that  position  the  hsemorrhoidal 
veins  have  no  support  from  surrounding  parts,  so  that  the 
straining,  by  forcing  the  blood  downward,  distends  them  into 
pouches,  or  varices.  When  the  rectum  is  continually  packed 
with  retained  faeces,  the  veins  are  compressed  above  the 
anus,  and  the  return  of  blood  being  restricted,  they  become 
additionally  distended  by  this  obstacle,  so  that  constipation 
is  a  leadinor  cause  of  the  disease.  The  contraction,  or  iuilam- 
matory  obstruction  of  the  "muscular  button-holes"  by  which 
the  superior  veins  emerge  from  the  rectum  is  also  supposed 
to  be  causes  of  their  dilatation,  and  hence  of  piles. 

Any  obstruction  of  the  portal  vessels  acts  in  the  same 
way,  hence  diseases  of  the  liver,  large  abdominal  tumors 
and  the  pressure  of  the  gravid  uterus  in  pregnancy  are  com- 
mon causes.  When  the  inflammation  of  acute  dysentery 
progresses  downward  to  the  vicinity  of  the  anus,  the  veins 
are  obstructed  by  inflammatory  deposits  around  them,  so  that 
piles  often  appear  in  the  later  stages  of  that  disease.    Finally 

21 


22  RECTAL   AND   ANAL  SURGERY. 

sundry  small  iijievoitl  tumors  of  the  anus,  as  well  as  liyper- 
tropliied  folds  of  the  skin  and  mucous  membrane,  soft 
polypi,  and  lumps  formed  by  clots  of  extravasated  blood 
under  the  skin,  are  popularly  classed  as  piles,  though  not 
properly  varices. 

In  cases  where  the  obstruction  is  temporary,  recent 
haemorrhoids  may  recover  spontaneously;  but  if  subjected  to 
the  continued  action  of  the  cause,  they  tend  to  enlarge  and 
become  more  and  more  inflamed.  At  first  they  are  trouble- 
some only  at  intervals,  but  these  "fits  of  piles"  grow  gradu- 
ally longer  and  ultimately  merge  into  each  other  so  that 
the  tumors  become  permanent.  As  the  distended  condition 
continues,  the  parts  become  inflamed,  and  the  integument 
and  the  connective  tissues  around  the  veins  become  first 
swollen  and  then  permanently  hypertrophied,  and  protuber- 
ances which  originated  as  mere  venous  pouches,  become 
solid  and  firm  fleshy  tumors.  Sometimes  clots  of  blood  form 
in  the  veins,  obliterating  them,  and  leading  to  their  cure  by 
atrophy.  At  other  times  the  veins  burst,  forming  globular 
clots  in  the  connective  tissue  outside  the  vessels,  and  these, 
like  all  other  lumps  in  this  region,  are  generally  termed 
piles.  They  sometimes  give  origin  to  suppuration  and  are 
discharged,  but  generally  the  clots  are  absorbed  in  the 
course  of  a  few  weeks.  Frequently  the  enlarged  veins  burst 
during  defecation  and  copious  haemorrhage  occurs.  Where 
this  occurs  daily,  the  patient  may  be  brought  to  the  verge  of 
death  from  an?emia. 

Piles  are  usually  divided  into  internal  and  external 
forms.  The  internal  are  those  which  originate  just  above 
the  verge  of  the  anus,  and  are  therefore  covered  with  mucous 
membrane.  They  are  primarily  varices  of  the  superior 
hsemorrhoidal  veins,  and  probably  may  originate  izi  disten- 
tion of  the  little  globose  blood  sacs,  described  in  the  chapter 
on  Anatomy  of  the  Rectum  as  being  the  starting  points  of 
the  radicles  of  these  veins.  Indeed,  there  are  those  who 
doubt  whether  these  sacs  are  anything  more  than  incipient 


HJEMORRHOIDS.    OR   PILES. 


23 


internal  hpemorrhoids,  though  there  is  respectable  authority 
for  their  normal  existence.      (Duret. ) 

At  first  internal  piles  only  appear  when  thriist  down  in 
defecation,  and  recede  out  of  sight  when  the  effort  is  over. 
As  they  grow  larger  they  are  gripped  by  the  sphincter  when 
down,  and  prevented  from  returning,  causing  much  pain, 
and  sometimes  bursting  under  the  muscular  grasp  of  the 
sphincter,  and  free  bleeding.  The  patient  now  learns  to 
relieve  his  pain  by  pressing  them  in  again  with  his  fingers. 
At  a  still  later  stage  they  often  become  too  large  to  remain 
in  at  all,  and  though  still  called  internal  piles  they  are  now 
habitually  external  in  position.     At  the  verge  of  the  anus, 

where  the  skin  joins  the  mucous 

membrane  the  subcutaneous  con- 
nective tissue  is  somewhat  denser 
than  above  or  below,  binding  the 
integument  there  closer  to  the 
inner  edge  of  the  external  sphinc- 
ter. This  circle  of  denser  tissue 
resists  the  distention  of  the  veins 
at  that  line,  so  that  we  usually  find 
the  internal  piles  above  separated 
by  a  narrow  groove  from  the  ex-  ^ 

ternal  piles  below.  However,  the 
dense  tissue  does  not  always  main- 
tain  its  grip,   and  we  often  find 

internal  and  external  piles  running  ^^^^^^^^  a/d  ExTtENAi.  Piles. 
into  each  other  with  no  groove  to 

mark  the  boundary  between  them.  In  short,  the  same  pile 
may  be  both  internal  and  external.  Physicians  often  speak 
of  suspected  internal  piles  high  up  in  the  rectum.  This  is 
an  error.  There  are  no  internal  piles  so  high  up  that  they 
never  show  during  defecation.  They  rarely  occur  more  than 
an  inch  above  the  verge. 

External  piles  are  specially  liable  to  become  obliterated 
by  thrombus,  suppuration,  etc.,  in  which  case  they  leave 


24 


RECTAL   AND   ANAL   SURGERY. 


sundry  projecting    tabs   and  folds   of    skin  which   are    still 
called  external  piles,  though  no  longer  containing  enlarged 

veins.     Most    of   the 
' '  temporary  piles  form- 

ed by  extravasated 
clots  are  also  in  the 
external  group. 

Owing     to     the 

translucency    of    the 

mucous    membrane 

internal  haemorrhoids 

^  show  the  color  of  the 

distended    veins    be- 
FiG.  15.  —  Internal  and  Extebnal    Piles    not 

Cleablt  Sepabable  with  a  Small  Polypus  lieatll,    and    are    OI    a 

GBOWING  ON  AN  InTEBNAL  PilE.  ^j^-^j^   ^^^^j^   ^^j^^.^ 

while  external  piles  approach  more  to  a 
pink  tint.  When  internal  piles  are  found 
protruding,  they  generally  present  a  rip- 
pled, irregular  surface  on  account  of  the 
presence  of  the  reticulated  ridges  of  the 
columns  of  Morgagni,  and  of  the  sacculi 
Horneri  among  them.  External  piles  on 
the  contrary  if  distended  are  smoother  in 
contour.  The  difference  is  well  shown  in 
Fig.  14,  page  23. 

The  skin  and  mucous  membrane  cover- 
ing piles  near  the  verge  of  the  anus  are 
excessively  sensitive,  but  the  mucous  mem- 
brane covering  the  upper  portion  of  in- 
ternal piles  is  nearly  devoid  of  sensibility, 
a  fact  which  should  influence  all  our  plans 
in  operating. 

Hsemorrhoidal  tumors  have  a  remark-     Pile    fobmed    by 

,  -  ,.,  ,  ,•  1  1  L      Globuled      Clot 

able  erectile  power,  not  mentioned  by  most     undee  the  Skin.— 
authors,  and  resembling  that  of  the  coiyi(s     (Smith.) 
spoiKjiosiim  of  the  penis.     This  singular  tendency  enables 


Fig.    16. 


External 


HEMORRHOIDS   OR   PILES.  25 

US  to  bring  internal  piles  into  A^eAv  for  examination  or  opera- 
tion, by  simply  irritating  tliem  by  a  slightly  rough  handling 
with  the  finger.  Under  the  touch  they,  in  a  few  moments, 
erect  themselves  to  their  full  size  and  are  readily  brought 
to  view. 

The  treatment  of  haemorrhoids  is  palliative  or  operative. 

Palliative  Treatment. — We  have  called  the  non-opera- 
tive measures  palliative,  for  in  the  majority  of  cases  they  fail 
to  make  a  real  cure,  and  only  mitigate  the  suffering,  yet  it  is 
true  that  in  recent  cases,  where  organic  changes  have  not  yet 
become  established  many  haemorrhoids  return  to  a  state  of 
nearly  perfect  health  under  palliative  treatment,  so  that  we 
may  say  that  in  such  cases  they  actually  assist  nature  to 
effect  a  real  cure. 

One  of  the  most  important  measures,  is  to  combat 
constipation,  because  the  pressure  of  the  fecal  mass  com- 
presses and  obstructs  the  superior  haemorrhoidal  veins,  and 
thus  distends  them  with  blood  and  produces  internal 
haemorrhoids.  Without  occupying  too  much  space  with  a 
topic  familiar  to  every  physician,  suffice  it  to  say  that  the 
mode  of  life,  the  diet,  and  the  medicine  are  all  regulated 
Avitli  a  view  to  producing  a  gentle  unirritating  looseness  of 
the  bowels. 

When  full  control  of  the  patient  can  be  had,  it  is  well 
to  place  him  for  some  days  in  a  horizontal  position,  with  a 
mild  astringent  wet  compress  bound  against  the  anus.  As 
defective  action  of  the  liver  causes  distention  of  the  superior 
haemorrhoidal  veins,  that  organ  should  be  regulated.  Strain- 
ing, or  "bearing  down"  distends  all  the  pelvic  veins; 
hence  the  patient  should  be  cautioned  against  all  such 
efforts.  Inflammation  of  the  bladder  often  causes  piles  by 
inducing  tenesmus  and  straining  at  the  frequent  micturitions ; 
hence  haemorrhoids  are  common  in  cystitis,  especially  if  a 
calculus  exists  in  the  bladder,  and  the  cure  of  the  urinary 
difficulty  greatly  relieves  the  rectal  trouble. 

Astringent  ointments  and  washes  with  anodyne  supposi- 


26  RECTAL   AND   ANAL  SURGERY. 

tories  are  favorite  })alliatives.  Tannin,  alum,  zinc  sulphate, 
plumbic  acetate,  and  carbolic  acid  may  be  used  in  almost 
any  form  and  combination.  The  opiates,  cocaine,  hyoscya- 
mus,  belladonna,  or  atropine,  iodoform  and  bismuth  are 
favorites  for  suppositories.  It  should  be  remembered  that 
all  the  astringents  of  the  tannin  group  are  incompatible  with 
morphine,  cocaine,  and  vegetable  alkaloids  and  salts  gener- 
ally. The  aim  in  the  use  of  washes  and  ointments  should 
be  to  get  an  astringent  effect,  but  never  an  irritation,  and 
the  strength  of  the  preparation  should  be  calculated  accord- 
ingly. Alum  and  tannin  may  be  used  in  almost  any  strength, 
but  sulphate  of  zinc  and  all  caustics  must  be  better  guarded. 
The  tissues  tolerate  from  two  to  four  times  more  of  an  article 
in  the  form  of  an  ointment,  than  in  a  wash. 

Compression  bulbs  have  been  invented  to  slip  into  the 
rectum,  and  gently  compress  and  support  internal  piles,  but 
are  not  very  effective  except  in  a  few  cases. 

The  application  of  decided  caustics  has  been  resorted 
to,  such  as  brushing  internal  piles  with  strong  nitric  acid,  or 
nitrate  of  silver,  or  chromic  acid.  Good  is  sometime  done 
in  this  way,  but  mischief  also  may  follow. 

Operative  Treatment  by  Stretching  the  Sphincter. — 
Perhaps  the  mildest  operation  upon  internal  or  half  internal 
piles  is  that  employed  by  the  French  surgeons,  Professor 
Verneuil  and  M.  Fontan.  It  consists  simply  in  making  a 
rather  slow  and  gentle,  but  complete  and  thorough,  dilatation 
of  both  internal  and  external  sphincters.  This  may  be  done 
by  dilating  instruments  or  by  introducing  gently  through 
the  sphincters  two  oiled  fingers  of  each  hand,  and  slowly 
pulling  the  sphincters  in  opposite  directions  until  they  are 
thoroughly  stretched  or  dilated.  An  anaesthetic  may  be 
needed.  Dilatation  succeeds  best  in  piles  not  already 
chronic.  We  have  not  fully  tested  the  plan  in  our  own 
practice,  but  French  authorities  claim  that  a  large  proportion 
of  haemorrhoids  are  radically  cured  by  this  manipulation.  It 
may,  therefore,   be  a  desirable  method,  especially  when  the 


HEMORRHOIDS   OR   PILES.  27 

patient  is  timid  and  cherishes  a  horror  of  ligatures  and 
instruments.  Yet  it  must  be  remembered  that  severe  and  long 
continued  inflammation  sometimes  follows  these  forced  dila- 
tations, and  in  these  cases  they  are  by  no  means  a  mild 
measure. 

Treatment  by  Ligature. — Probably  the  English  and 
American  surgeons  have  favored  ligation  for  internal  piles 
more  than  any  other  plan,  on  account  of  its  comparative 
safety  from  haemorrhage,  embolism  and  abscesses.  Dr. 
Allingham,  of  London,  surgeon  of  St.  Mark's  Hospital  for 
Rectal  Diseases,  has  been  the  most  conspicuous  champion 
of  the  method,  but  Konig,  of  Gottingen,  and  many  others  on 
the  continent,  also  favor  it. 

The  application  of  the  ligature  renders  haemorrhage 
nearly  impossible,  and  puts  a  very  efficient  barrier  against 
the  entrance  of  clots  or  septic  material  into  the  channels  of 
the  veins. 

The  use  of  the  ligature  for  piles  is  very  ancient.  Hip- 
pocrates mentions  it,  and  Celsus  describes  it.  The  success 
is  excellent.  When  properly  done,  the  cure  is  as  near  to 
absolute  certainty  as  surgical  operations  ever  attain,  and  the 
danger  is  a  mere  trifle.  The  mortality  thus  far  ascertained 
is  nearly  as  follows: 

CASES.     DEATHS. 

Allingham's  report  of  cases  in  St.  Mark's  Hospital 

up  to  1859,         ------ 

Allingham's  report  of  cases  in  St.  Mark's  Hospital 

since  1858,         -         -         -        \- 
Allingham's  report  of  cases  in  St.  Mark's  Hospital 

since  previous  report,  -         -  -  - 

Allingham's  private  practice,      -  .  -  . 

Total,  - 5,863  6 

This  is  about  one  death  in  a  thousand  cases.  It  should 
be  noted  that  five  of  these  deaths  occurred  previous  to  1859, 
when  antiseptics  were  unknown  and  the  hospitals  of  London 
were  in  a  very  unhealthy  condition.      Since  that  Allingham 


1,763 

5 

2,250 

1 

250 

0 

1,600 

0 

28  RECTAL   AND   ANAL  SURGERY. 

reports  4,100  cases  with  only  one  death.  The  following 
authors  have  expressed  their  opinion  in  favor  of  ligation: 
Gross,  Van  Buren,  Bodenhamer,  Gowlland,  Alfred  Cooper, 
Curling,  Quain,  Ashton,  Syme,  Bushe,  Copeland,  Sir  Benja- 
min Brodie,  Konig,  Frank  Hamilton,  Ashurst,  Cripps,  and 
many  others. 

Preparation  of  the  Patient  for  Operation. — It  is  best 
to  investigate  the  })atient's  whole  condition,  and  rectify  as 
perfectly  as  possible  all  diseased  tendencies.  Bright's 
disease  of  the  kidneys  adds  greatly  to  the  risk  of  all  opera- 
tions, and  such  cases  are  to  be  avoided  if  possible.  Cripps 
refuses  operations  also  in  all  cases  of  piles  dependent  on 
cystitis,  but  this  is  an  error.  When  cystitis  and  piles  co- 
exist, each  one  powerfully  aggravates  the  other,  and  the 
cure  of  the  piles  greatly  assists  the  cure  of  the  bladder. 
Many  times  the  latter  can  never  be  cured  until  the  piles  are 
operated  on.  In  malarious  regions  a  full  dose  of  quinine 
four  times  a  day  for  forty-eight  hours  is  a  good  preparation 
for  the  operation.  The  hair  about  the  anus  should  be  shaved 
off,  and  an  antiseptic  wash  used  there  three  times  daily  for 
two  or  three  days.  A  good  solution  is  carbolic  acid,  one  part 
to  fifty,  or  corrosive  sublimate,  one  part  to  three  thousand  of 
water.  On  the  day  of  operation  the  bowels  should  be  well 
emptied  by  a  cathartic,  and  the  meal  next  preceding  the 
operation  should  be  omitted,  so  as  to  avoid  vomiting  during 
the  anaesthesia. 

When  one  or  two  small  piles  only  are  to  be  operated 
on,  they  can  be  anaesthetized  sufficiently  by  clamping  their 
bases  and  in  that  state  injecting  them  with  cocaine;  but 
where  the  disease  is  extensive,  ether  is  necessary.  If  the 
latter  is  used,  the  patient  should  strain  down  the  piles,  if 
possible,  just  before  the  operation,  so  as  to  bring  them  to 
view,  and  then  go  upon  the  table  and  be  anaesthetized.  After 
etherization,  he  may  be  placed  in  the  position  of  lithotomy, 
or  upon  either  side,  with  the  knees  drawn  up,  at  the  pleasure 
of  the  operator. 


HEMORRHOIDS   OR   PILES.  29 

Most  surgeons  now  forcibly  dilate  the  sphincter,  which 
excites  the  erectile  action  of  the  piles,  and  also  opens  the 
anus,  thus  bringing  the  tumors  well  into  view.  It  is  done 
by  inserting  one  or  two  fingers  of  each  hand  into  the  anus, 
and  gently  but  steadily  drawing  in  opposite  directions  for 
three  or  foar  minutes.  All  rapid  traction  is  to  be  guarded 
against,  because  there  is  danger  of  rupturing  the  tissues. 
It  is  not  true,  however,  as  some  writers  imply,  that  this 
dilatation  is  necessary.  We  can  assert  from  many  years  of 
experience  that  ligation  without  forced  dilatation  is  one 
of  the  most  successful  operations  in  surgery,  so  much  so 
that  it  rarely  fails  to  cure;  sometimes  it  has  seemed  to  us 
that  when  we  have  employed  the  dilatation,  the  patient  has 
suffered  severe  pain  and  inflammation  without  any  better 
final  result.  We  doubt  the  wisdom  of  inflicting  this  added 
injury  indiscriminately.  In  many  cases  the  piles  are  suffi- 
ciently exposed  already,  and  in  most  of  the  remainder  a 
slightly  rough  handling  of  them  with  the  finger  and  forceps, 
or  tenaculum,  causes  the  erection  before  described,  and 
enables  one  to  bring  them  well  into  view.  The  irritation 
of  a  forced  dilatation  may  be  avoided  whenever  it  is  un- 
necessary, yet,  the  parts  just  above  the  verge  must  be  well 
searched,  lest  hidden  piles  escape  notice  and  make  future 
trouble. 

We  next  consider  the  number  and  size  of  the  piles,  for 
if  they  occupy  the  whole  verge  of  the  anus,  an  absolutely 
complete  removal  of  them  down  to  their  bases  will  make  a 
circular  wound  completely  surrounding  the  orifice,  whose 
contraction  in  healing  will  cause  a  stricture  of  the  anus, — a 
fact  which  many  eminent  authors  strangely  neglect  to  mention. 
It  is  necessary  in  all  cases  to  save  mucous  membrane  enough 
to  constitute  a  soft  and  distensible  verge  to  the  anus.  Hence, 
when  the  piles  occupy  the  whole  rim,  we  do  not  tie  them 
close  to  their  bases,  but  about  half  way  between  the  base 
and  summit,  so  as  to  leave  some  mucous  membrane  and  skin 
between    the    tumors,  and    not    included   in    the   ligatures. 


30  RECTAL   AND   ANAL  SURGERY. 

There  need  be  no  fear  of  failure  on  this  account.  Although 
the  ligature  takes  oft'  only  half  the  height  of  each  })ile,  the 
stumps,  after  swelling  temporarily,  always  shrink  down  and 
become  atrophied,  leaving  a  perfect  cure.  Having  con- 
sidered thus  where  to  place  the  ligatures,  the  surgeon  seizes 
a  pile  with  small  vulsellum  forceps,  or  a  tenaculum,  and 
draws  it  out.  At  this  stage  Allingham  takes  a  pair  of 
scissors,  and  commencing  at  the  white  line  where  the  lower 
end  of  the  mucous  membrane  covering  the  pile  joins  the 
skin,  dissects  it  up  from  the  sphincter  some  slight  distance 
into  the  bowel,  keeping  close  to  the  muscular  coat.  The 
wound  does  not  bleed  much,  because  the  arteries  of  the  pile 
enter  it  at  its  superior  border.  This  incision  severs  the 
nerves  of  sensation,  which  enter  from  below,  and  makes  the 
presence  of  the  ligature  less  painful.      However,  when  the 

pil  es  constitute  almost 
a  continuous  ridge 
around  the  anus,  this 
plan  cannot  be  adopt- 
ed, as  a  ring-shaped 

Fig.  17.  woundaudsubsequent 

Small  Vulsellum  Fokceps  fob  Piles.  j.   •    i  -ii  i. 

stricture  will  result. 
This  deep  dissection  also  is  not  free  from  chances  of  haemor- 
rhage. Arteries  sometimes  take  abnormal  directions,  and 
scissors  also  go  at  times  a  little  deeper  than  was  intended. 
Hence  many  surgeons  prefer,  after  seizing  the  pile,  to  cut  a 
little  groove  at  the  proper  place,  around  the  lower  half  of  its 
circumference,  simply  going  through  the  integument,  so  as 
to  divide  the  cutaneous  nerves,  and  thus  blunt  the  sensibility 
and  prevent  the  pain  which  would  otherwise  occur  after  the 
anaesthesia  passes  away.  The  ligature,  which  should  be  very 
strong,  is  tied  in  the  groove  made  by  the  knife,  and  if  the 
pile  is  large  it  should  be  tied  three  times  around,  as  other- 
wise the  yielding  of  the  tissue  under  the  pressure  of  the 
ligature  is  liable  to  slack  its  tightness  and  prevent  complete 
strangulation.      After  tying  the  knots  very  securely  it  is  best 


HEMORRHOIDS   OR   PILES.  31 

to  snip  off  the  summit  of  each  tumor,  hut  not  to  cut  so 
closely  to  the  ligature  as  to  risk  the  latter's  slipping  off. 
We  prefer  silk,  hemp  or  linen  threads.  Catgut  can  be  used. 
but  it  needs  special  care  in  tying,  as  under  the  softening 
effect  of  moisture  it  becomes  slippery  and  is  liable  to  yield, 
and  permit  haemorrhage.  Chromicized  catgut  is  partly  free 
from  this  danger.  Many  tr}-  to  press  the  ligature  stumps 
back  into  the  bowel,  but  we  are  of  the  opinion  that  there  is 
no  use  in  that  procedure.  If  they  remain  outside  they  can 
be  kept  w^ell  disinfected,  and  all  bad  odor  and  danger  of 
septic  infection  prevented.  The  operation  being  finished 
the  stumps  should  be  washed  with  an  antiseptic  solution, 
dressed  with  iodol  or  iodoform  and  covered  with  a  handful 
of  antiseptic  gauze  held  in  position  by  a  T  bandage. 
Anodynes  may  be  given  as  required,  and  it  is  well  to  give  a 
hypodermic  injection  of  morphine  just  before  the  operation. 
By  a  careful  application  of  an  eight  per  cent,  solution  of 
cocaine  externally,  or  of  a  four  per  cent,  solution  by  a 
hypodermic  syringe  under  the  skin  and  mucous  membrane 
of  the  anus,  many  mild  cases  can  be  ligated  with  but  little 
pain  without  any  ether  or  chloroform,  but  care  must  be 
taken  not  to  exceed  a  safe  dose.  A  young  surgeon  in  New 
York  trying  to  operate  under  cocaine,  and  not  getting  full 
anaesthesia,  yielded  to  the  temptation  to  repeat  the  dose 
until  he  had  injected  eighteen  grains  into  the  tissue  of 
the  rectum,  causing  the  death  of  the  patient.  Overcome 
with  horror  at  the  result  of  his  error  he  then  committed 
suicide. 

Frequently  the  operation  will  be  followed  by  a  spas- 
modic contraction  of  the  sphincter  of  the  bladder,  causing 
retention  of  urine,  and  compelling  a  resort  to  the 
catheter  once  or  several  times.  The  catheter  may  be  tied  in 
if  necessary.  Some  surgeons  try  to  prevent  the  spasm  of 
the  neck  of  the  bladder  by  dilating  it  with  a  large  urethral 
sound  at  the  close  of  the  operation.  The  treatment  of  the 
bowels  is  not  agreed  upon  among  surgeons.     If   they  are 


32  RECTAL   AND   ANAL   SURGERY. 

made  to  operate  daily  they  cause  a  repetition  of  the  painful 
movement.  If  they  are  restrained  by  opiates  several  days, 
as  advised  by  AlliniJ^ham,  the  fecal  mass  in  the  rectum 
becomes  large,  and  hurts  the  more  violently  at  last.  The 
best  way  is  to  empty  the  bowels  thoroughly  before  operating, 
and  allow  but  little  solid  food  for  three  days  after.  At  the 
end  of  some  two  or  three  days  after  the  operation  give  a 
mild  cathartic,  and  at  the  same  time  soften  the  contents  of 
the  rectum  by  a  warm  injection.  This  will  cause  an  evacu- 
ation with  but  little  pain,  and  by  similar  means  we  can 
procure  daily  painless  movements  afterward,  especially  if  the 
parts  be  well  brushed  with  cocaine.  On  the  whole  we 
prefer  the  ligature  to  other  operations  in  almost  all  internal 
haemorrhoids,  on  account  of  the  superior  safety. 

Treatment  of  Haemorrhage  after  Operations  in  the 
Rectum. — All  operations  for  piles  are  liable  to  a  possible 
primary  or  secondary  hjiemorrhage,  thoiigh  the  method  by 
ligature  is  nearly  safe  from  this  accident.  As  the  bleeding 
may  take  place  inside  the  sphincter,  a  great  quantity  of 
blood  may  accumulate  in  the  colon  before  it  is  observed. 
If  haemorrhage  is  discovered,  or  suspected,  the  bleeding 
point  must  be  sought  for,  even  if  one  has  to  forcibly  dilate 
the  anus  and  pull  down  the  mucous  membrane.  The  spot 
cannot  be  much  above  the  verge.  If  it  cannot  be  discovered 
Allingham  ties  a  double  string  into  the  center  of  a  large 
bell-shaped  sponge,  and  pushes  it  up  five  inches  above  the 
bleeding  point,  so  as  to  prevent  the  blood  escaping  upward 
into  the  colon.  He  then  firmly  packs  the  parts  below  with 
cotton  dusted  with  powdered  alum  or  iron  persulphate,  and 
leaves  the  tampon  there  a  week  or  more.  If  the  bleeding 
point  can  be  found  approximately,  but  not  exactly,  the  whole 
adjacent  patch  of  mucous  membrane  can  be  pinched  up  and 
tied  en  masse,  or  a  double  ligature  may  be  passed  under  the 
spot  by  a  curved  needle  and  tied  each  way,  thus  enclosing 
the  bleeding  spot. 

Slighter  haemorrhage  may  often  be  arrested  by  ice  in 


HEMORRHOIDS   OR   PILES.  33 

the  rectum,  or  bj  astringent  tampons,  but  severe  cases  require 
ligatures. 

The  Hypodermic  Injection  of  Piles,  or  the  Method  of 
Itinerants. — In  the  year  isTl  there  lived  in  the  villao-e  of 
Clinton,  Illinois,  a  young  jihysician  named  Mitchell.  His 
practice  was  small,  aiid  afforded  him  superabundant  leisure, 
which  he  employed  in  devising  a  new  treatment  for  piles. 
Being  a  good  thinker  he  soon  conceived  the  idea  of  treating 
haemorrhoids  by  the  hypodermic  injection  of  a  mixture  of 
olive  oil  and  carbolic  acid.  Having  tried  his  plan  upon  an 
old  farmer  of  the  neighborhood  he  accomplished  a  triumphant 
cure.  The  old  farmer  was  delighted  and  garrulous,  and  the 
young  doctor  was  needy  but  ambitious,  and  the  two  made  a 
sort  of  copartnership,  the  old  farmer  attending  to  the  adver- 
tising, while  the  young  doctor  received  the  patients  and 
punctured  their  piles  and  their  pockets  with  his  hypodermic 
syringe.  Knowledge  of  their  method  spread.  Certain 
itinerants  began  to  sell  the  secret  to  others,  pledging  them 
•to  secrecy  in  turn,  and  binding  each  to  practice  only  in  the 
district  for  which  he  had  "  purchased  the  right."  Two  men 
in  Chicago  are  said  to  have  paid  three  thousand  dollars  for 
the  exclusive  secret  "  right "  to  a  certain  portion  of  Illinois, 
including  their  city.  Flocks  of  itinerants  bought  the  secret 
of  each  other,  and  traversed  the  country  in  every  direction 
until  their  handbills  fluttered  on  the  shores  of  the  Pacific 
Ocean.  In  the  year  1876  one  of  the  quacks  revealed  to 
us  his  method,  and  by  taking  measures  adapted  to  the  pur- 
pose we  found  that  his  information  was  correct.  We  then 
entered  into  correspondence  with  a  cojisiderable  number  of 
the  itinerants,  some  of  whom  seemed  willing  to  make  a  clean 
breast.  We  also  communicated  with  a  large  iiumber  of 
regular  physicians  who  had  observed  the  practice  of  the 
itinerants,  and  in  some  cases  had  made  use  of  the  method 
ttiemselves.  In  the  course  of  this  investigation  we  received 
about  300  letters,  and  got  rough  estimates  of  the  results  of 
the  injections  in  about  3,300  cases. 


34  RECTAL   AND   ANAL   SURGERY. 

Mitchell  commenced  with  a  mixture  of  one  part  of 
carbolic  acid  to  two  parts  of  olive  oil,  but  he  gradually 
varied  from  liis  first  method,  and  at  length,  as  I  am  informed, 
he  partly  abandoned  the  injections  and  adopted  the  plan  of 
tearing  the  interior  of  the  piles  to  pieces  by  angular  needles 
set  in  handles.  He  probably  met  some  of  the  dangerous 
accidents  which  have  occurred  in  the  injection  practice,  and 
changed  to  the  needles  on  that  account.  His  disciples, 
however,  persisted,  and  in  their  hands  the  injections  were 
varied  in  numerous  ways.  One  of  the  itinerants  wrote  us 
that  he  had  tested  "  every  caustic  in  the  vegetable  and 
mineral  kingdoms,"  but  that  he  came  back  to  carbolic  acid 
as  the  best,  "and  the  stronger  the  better." 

The  excipients  generally  used  were  oil,  glycerine  or 
alcohol,  to  which  water  was  sometimes  added.  Carbolic 
acid  was  generally  but  not  always  the  active  ingredient  and 
the  strength  varied  from  twenty  to  one  hundred  per  cent. 
We  were  disappointed  on  the  whole  in  the  results.  Although 
there  were  many  beautiful  cures,  thirteen  deaths  were 
reported  to  us  out  of  about  3,304  cases,  besides  a  large 
number  of  dangerous  abscesses,  sloughings,  and  in  some 
cases  prolonged  and  terrible  pain,  or  desperate  shock,  the 
latter  being  probably  from  embolism.  In  a  number  of 
cases  very  dangerous  hsemorrhages  occurred,  presumed  to 
be  from  the  spasmodic  grip  of  the  sphincter  bursting  the 
thin  walls  of  a  pile,  squeezing  out  the  clot,  and  letting  loose 
the  floodgates  of  the  hsemorrhoidal  veins,  which  above  the 
verge  have  no  valves. 

It  is  an  old  experience  over  again.  Twenty  years  ago 
the  profession  was  charmed  by  the  results  of  coagulating 
injections  thrown  into  venous  enlargements  in  other  parts  of 
the  body,  but  we  were  soon  stopped  by  the  occurrence 
of  deaths  from  embolism.  The  hypodermic  injection  of 
piles  confronts  us  with  similar  dangers. 

The  following  accidents  have  been  reported  to  us  out  of 
about  8,304  cases:    Deaths,  13;  embolism  of  liver,  8;  sudden 


HEMORRHOIDS   OR   PILES.  35 

and  dangerous  prostration,  1 ;  abscess  of  liver.  1 ;  dangerous 
haemorrhage,  10;  permanent  impotence,  1;  stricture  of  the 
rectum,  2;  violent  pain,  83;  carbolic  acid  poisoning,  1; 
failed  to  cure,  19;  severe  inflammation,  10;  slouo'hingf  and 
other  accidents,  35. 

We  are  the  more  particular  to  mention  these  disasters, 
because  Dr.  C.  B.  Kelsey,  of  New  York,  has  recently  tried 
the  plan  and  states  that  he  has  never  heard  of  a  death 
from  it.  Our  expei-ience  in  the  West  is  very  different. 
Twelve  years  ago  we  published  nine  of  these  deaths  in  an 
article  which  was  extensively  republished  in  the  medical 
journals  of  this  country  and  of  Europe,  and  about  four  more 
fatal  cases  have  come  to  our  knowledge  since.  Dr.  Kelsey, 
like  one  of  the  present  writers,  was  at  first  highly  pleased 
with  his  results,  but  with  his  usual  sound  judgment  and 
candor  he  observes  that  further  experience  developed  so 
many  instances  of  abscesses,  sloughing,  etc.,  etc.,  that  he 
has  modified  his  first  conclusions,  and  now  applies  the  j^lan 
mainly  to  selected  cases  of  completely  internal  piles  of 
moderate  size,  and  having  well  defined  pedicles.  (Kelsey 
on  the  Treatment  of  Haemorrhoids,  p.  64. ) 

For  ourselves,  we  were  long  ago  reluctantly  compelled 
to  admit  that  these  injections  are  dangerous,  and  until  some 
way  of  avoiding  the  perils  is  shown  we  can  not  recommend 
them  except  in  special  and  selected  cases. 

The  itinerants  varied  greatly  the  strength  of  the 
fluids  used.  The  weak  solutions  acted  more  mildly  than 
the  others,  but  they  often  failed  of  cure.  The  strong 
preparations  almost  always  cured  the  piles,  but  they  pro- 
duced a  multitude  of  cases  of  abscesses  and  sloughings.  The 
Michigan  itinerant  above  mentioned  states  that  he  preferred 
positive  results,  and  always  sought  to  cause  the  piles  to 
suppurate  or  mortify,  and  to  that  end  he  "preferred  carbolic 
acid,  and  the  stronger  the  better."  Some  of  them  use  the 
acid  at  a  strength  of  only  three  per  cent,  and  others  as  high 
as  95  per  cent. 


36  RECTAL  AND   ANAL  SURGERY. 

The  secret  pile  remedy  of  the  "  Brinkerhoff  System,"  is 
the  following: 

Carbolic  Acid 3 j 

Olive  Oil :v 

Chloride  of  Zinc grs.  viij 

Mix. 

The  little  pamphlet  furnished  to  the  itinerants  pur- 
chasing the  "  System  "  directs  that  the  amount  of  injection 
Inserted  into  the  tumors  shall  be  as  follows: 

Largest  Piles 8  minims 

Medium     "     4  to  8      " 

Small         "     2  to  3      " 

Club-shaped  painless  piles  near  orifice       2       " 

"  Brinkerhoff's  System "  forbids  the  injection  of  any 
but  internal  piles.  He  directs  hot  sitz-baths  for  cases  where 
violent  pain  follows.  His  prohibition  against  the  injection 
of  the  external  kind,  is  doubtless  because  of  the  agonizing 
distress  apt  to  follow  in  the  latter,  owing  to  their  great 
supply  of  sensory  nerves.  He  directs  to  treat  only  one 
large,  or  two  small  piles  at  a  sitting,  and  to  allow  from  two 
to  four  weeks  between  the  operations. 

Some  add  ergot,  and  others  cocaine  to  their  injections. 
The  itinerants  have  used  a  great  variety  of  coagulating 
substances  besides  carbolic  acid,  such  as  iron  persulphate, 
iron  perchloride,  zinc  sulphate,  zinc  chloride,  mineral  acids, 
tannic  acid,  etc.,  but  on  the  whole  carbolic  acid  mixtures 
have  received  the  preference.  The  dangers  have  generally 
arisen  from  embolism,  haemorrhage,  abscesses  and  septicaemia. 
The  lower  portion  of  the  heemorrhoidal  plexus  empties  into 
the  iliac  veins,  and  the  upper  into  portal  system ;  hence  clots 
or  globules  of  the  injection  may  be  carried  either  to  the 
heart  or  to  the  liver.  Dr.  Whitmire,  a  well-known  physician 
of  high  standing  at  Metamora,  111.,  tampons  the  rectum  for 
twenty-four  hours  after  the  injection  to  prevent  the  clots 
from  moving  upward.     In  case  of  haemorrhage,  Allingham's 


HEMORRHOIDS   OR   PILES.  37 

method  of  tamponing,  as  described  ou  page  32,  can  be 
employed. 

Up  to  the  present  time  science  has  not  discovered  any 
method  o£  wholly  avoiding  the  risks  of  the  hypodermic 
injections.  The  method  is  moderately,  but  positively 
dangerous,  and  we  cannot  recommend  it  as  proper  in 
ordinary  cases. 

If  the  injection  plan  is  resorted  to  at  all  the  following 
rules  should  guide  us: 

1.  Unless  cocaine  is  used,  inject  only  internal  piles,  as 
those  have  much  less  susceptibility  to  pain  than  the  external 
ones;  however,  if  an  external  pile  be  injected  a  few  minutes 
beforehand  with  cocaine,  the  pain  can  be  in  a  great  measure 
prevented. 

2.  Use  diluted  forms  of  the  injection  first,  and  stronger 
ones  only  when  these  fail. 

3.  Inject  only  one  or  two  piles  at  a  time,  and  alloM' 
from  ten  to  thirty  days  between  the  operations. 

4.  Apply  cosmoline  to  the  surface  to  protect  it  from 
possible  dripping  during  the  operation,  and  keep  the  syringe 
in  a  few  moments  to  prevent  the  mixture  from  flowing  out. 
Inject  slowly. 

5.  Confine  the  patient  to  the  bed  the  fii-st  day. 

Treatment  of  Haemorrhoids  by  the  Clamp  and  Cau- 
tery.— Yon  Langenbeck,  of  Berlin,  and  Smith,  of  London, 
are  the  chief  advocates  of  this  operation,  but  Mr.  Cusacle,  of 
Dublin,  is  said  to  be  the  inventor  of  it.  The  operator  seizes 
the  pile  with  a  double  tenaculum  or  with  a  small  vulsellum 
forceps  and  draws  it  out.  He  then  applies  to  its  base  the 
clamp  shown  in  Fig.  18,  so  as  to  prevent  hasmorrhage  and 
protect  the  parts  beneath  from  the  cautery  instruments. 
Smith  then  cuts  off  the  piles  outside  the  clamp  with  hot 
serrated  cautery  knives,  while  others  simply  use  the  scissors. 
In  either  case  the  tissue  is  not  divided  close  to  the  clamp, 
but  about  a  quarter  or  third  of  an  inch  external  to  it.  The 
projecting  stump  is  now  thoroughly  but  slowly  cauterized  by 


38 


RECTAL   AND   ANAL  SURGERY. 


irons  at  a  black  lieat,  so  applied  as  not  merely  to  sear  the 
cut  surface,  but  to  thoroughly  "cook"  the  whole  projecting 
stump  well  up  to  the  clamp.  The  electro-cautery  can  be 
used  instead  of  hot  irons. 

The  method  effectually  cures  the  piles,  but  it  is  a  little 

more  liable  to  haemorrhage  than 
the  ligature,  and  the  idea  of 
burning  the  parts  with  hot 
irons  is  horrifying  to  the  imag- 
ination of  the  patient  and  his 
friends,  hence  the  clamp  has 
had  less  favor  than  the  liga- 
ture, though  many  excellent 
surgeons  employ  it.  The  after- 
treatment  is  the  same  as  that 
after  ligation. 

Treatment  of  Haemor- 
rhoids by  the  Ecraseur. — 
Many  French  surgeons  former- 
ly favored  the  removal  of  piles 
by  the  chain  ecraseur.  We  have 
often  used  for  the  purpose  the 
Ecraseur  forceps  here  shown 
(Fig.  19)  which  are  of  our  own 
devising,  though  by  an  accident 
they  are  credited  in  the  instru- 
mental catalogues  to  Professor 
Byford.  The  error  was  not  due 
to  him,  as  he  never  laid  any 
claim  to  the  invention. 

The  instrument  is  easily 
-Smith's  Cauteey  Clamp,  gleaned,  simple  in  structure, 
and  much  more  easily  applied  than  the  complicated  chain 
Ecraseur,  and  does  not  break  like  the  wire  ecraseur.  The 
effect  on  the  pile  is  exactly  the  same  as  that  of  the  others, 
neither  better  nor  worse.     Smith,  of  London,  has  devised 


Fig.  18. 


HEMORRHOIDS   OR  PILES. 


39 


a  small  pile  ecraseur  (Fig.  20),  using  a  wire  cable  instead 
of  a  chain. 

The  pile  being  seized  with  vulsel- 
lum  forceps,  the  instrument  is  applied 
at  the  same  point  where  a  ligature 
would  be,  generally  half  way  between 
the  base  and  the  summit,  and  slowly 
tigfhtened  until  the  tissues  are  severed. 
The  patient  must  be  kept  some  days  in 
bed,  the  stumps  are  treated  antisepti- 
cally,  and  the  general  management  is 
the  same  as  after  ligature.  As  in  all 
other  methods  of  removing  piles,  it  is 
necessary  to  be  careful  and  leave  suffi- 
cient mucous  membrane  to  make  a  dis- 
tensible verge  of  the  anus,  otherwise  a 
stricture  will  follow. 

The  ecraseur  cures  piles  effectu- 
ally, but  it  is  occasionally  followed  by 
dangerous  haemorrhage,  so  that  its 
popularity  in  this  country  has  decidedly 
weaned.  In  our  own  practice  we  have 
discarded  its  use. 

Crushing  the   Pile. — Another      fill  m/ 

method  consists  in  crushing  the  pile 
with  an  instrument  devised  for  the  pur- 
pose, without  removing  it.  This  merely 
diminishes  the  danger  of  haemorrhage 
without  attaining  the  safety  of  ligation. 
It,  however,  destroys  the  pile,  and  causes 
it  to  slough  off,  thus  effecting  a  cure. 
It  has  been  considerably  but  not  gener- 
ally employed.  It  is  a  more  severe  opera- 
tion than  ligation  and  has  no  advantage        ^^^-  19-    Authok's 

^  .         .  "  ECBASEUB-FOEOEPS. 

over  other  methods  in  its  results. 

Various  Cauteries. — Hot  irons  of  various  forms  have 


40 


RECTAL   AND   ANAL  SURGERY. 


been  applied  to  piles  with  the  effect  of  curing  the  tumors. 
Cautery  by  needles,  either  heated  by  a  spirit  lamp  or  by  the 
galvanic  current,  has  been  a  favorite  with  some.  Electricity 
in  a  weaker  current  is  also  used  to  coagulate  the  blood  in 
the  piles  with  considerable  effect. 

Potential  cautery  has  been  practiced  on  internal  haemor- 
rhoids with  fuming  nitric  acid,  with  sodium  ethylate,  and 
with  potassa  cum  calce.  Many  successes  and  many  failures 
have  resulted  from  the  use  of  these  inconvenient  articles. 

Treatment  of  External  Piles. — External  ha3morrlioids 
may  be  excised,  ligated,  or  destroyed  by  cautery.  When 
they  consist,  however,  of  globular  subcutaneous  blood  clots, 
operation  is  unnecessary  because  they  will  be  absorbed  in  a 


Fig.  20. — Smith's  Wike  Cable  Eckaseue. 

few  weeks  or  months.      If  painful  they  may  be  slit  up  and 
the  clots  turned  out. 

Excision  of  Internal  Piles. — A  few  aiithors  have  lately 
advocated  a  partial  return  to  the  discarded  plan  of  cutting 
out  internal  as  well  as  external  piles,  resorting  to  one  or 
another  method  of  preventing  haemorrhage,  according  to  the 
fancy  or  the  judgment  of  the  writer.  We  are  sorry  to  say 
that  none  of  these  plans  are  safe.  One  may  operate  a  hun- 
dred times  and  have  no  trouble,  but  sooner  or  later  the 
surgeon  who  cuts  out  large  numbers  of  internal  piles  will 
have  instances  of  dangerous  haemorrhage.  If  the  incision 
were  external,  where  unskilled  attendants  could  apply  com- 
pression, it  would  be  less  objectionable,  but  the  bleeding 
point  is  above  the  sphincter,  and  the  patient  bleeds  a  colon- 
full  before  he  knows  the  cause  of  his  faintness.     He  then 


HEMORRHOIDS   OR   PILES. 


41 


expels  a  great  mass  of  clots,  and  the  sphincter  closes,  stop- 
ping the  external  How  and  deceiA'ing  the  patient  with  a  false 
appearance  of  improvement,  until  an- 
other mass  is  expelled,  and  so  on  through 
a  perilous  series  of  refiUings  and  expul- 
sions. If  the  surgeon  who  operated 
happens  to  be  inaccessible,  or  not  to  be 
found,  the  patient  will  be  in  great  dan- 
ger, for,  even  if  some  well-educated 
physician  not  in  surgical  practice  is 
called,  he  will  often  be  baffled  and  per- 
plexed to  control  a  bleeding  from  an 
internal  point,  whose  exact  location  is 
very  obscure  to  him. 

For  the  method  of  arresting  rectal 
haemorrhage  the  reader  is  referred  to 
page  32. 

The  Circular  Excision,  or  White- 
head's Operation,  —  Mr. 
Whitehead,  of  England, 
published  in  the  British 
Medical  Journal  nearly 
five  years  ago  a  new  plan 
of  operation,  which  was 
very  energetic,  but  involv- 
ed some  dangers,  and  was 
not  tlierefore  acceptable  to( 
most  surgeons.  Professor 
Eobt.  F.  Weir,  of  New 
York,  tried  it,  however, 
but  soon  abandoned  it  on 
account  of  its  obvious  de- 
fects. Mr.  Whitehead  him- 
self became  dissatisfied  with  his  method  and  in  February, 
1887,  published  in  the  Brifish  Medical  Jourmd  a  modifica- 
tion of   the   plan,   and   claimed  complete   success  in  three 


Fig.  21. — Nott's  Ecbaseub. 


42  RECTAL   AND   ANAL  SURGERY. 

hundred  consecutive  cases  without  a  single  death,  secondaiy 
haemorrhage,  abscess,  ulceration,  stricture  or  incontinence 
of  the  ffBces.  Notwithstanding  these  brilliant  claims  the 
method  is  liable  to  several  objections,  so  much  so  that  we 
have  declined  thus  far  to  use  it,  but  Prof.  Weir,  after  trying 
it  six  times,  announces  his  approval  of  it. 

Mr.  Whitehead's  improved  procedure  is  as  follows: 
The  sphincters  are  lirst  forcibly  stretched.  Next  the 
surgeon  with  dissecting  forceps  picks  up  the  integument 
near  the  junction  of  the  skin  and  mucous  membrane  and 
with  scissors  cuts  through  the  mucous  membrane  at  or 
pretty  near  the  white  line  indicating  its  junction  with  the 
skin,  making  a  rapid  incision  entirely  around  the  bowel  and 
upward  until  the  upper  edge  of  the  external  sphincter 
and  the  lower  edge  of  the  internal  one  are  exposed  to  view. 
The  dissection  is  then  carried  upward  along  the  inner 
surface  of  the  internal  sphincter  separating  the  piles  and 
mucous  membrane  from  the  muscle,  pulling  the  piles  down- 
ward a  little  firmly  and  snipping  any  resisting  bands  of 
tissue,  but  using  the  fingers  and  handle  of  the  scalpel  as  far 
as  possible  to  peel  the  piles  away  from  the  muscle  until  the 
healthy  membrane  above  the  piles  is  reached.  The  mucous 
membrane,  now  hanging  loose  in  the  rectum  with  the  piles 
attached,  is  divided  transversely,  cutting  only  a  moderate 
portion  of  it  at  a  time,  and  securing  the  bleeding  vessels  by 
torsion  and  not  by  ligatures.  As  soon  as  the  vessels  of  a 
section  are  secured,  that  portion  of  the  cut  edge  of  the 
mucous  membrane  is  dusted  with  iodoform  and  pulled  down 
and  fastened  by  fine  silk  sutures  to  the  cut  edge  of  integu- 
ment at  the  verge.  The  stitches  are  never  removed  but 
allowed  to  fall  out  spontaneously.  Another  portion  of  the 
circumference  is  then  cut,  and  secured  in  the  same  manner 
and  so  on  until  the  whole  of  the  circumference  is  divided, 
and  the  circle  of  mucous  membrane  which  naturally  lined 
the  lower  part  of  the  rectum  is  taken  away,  and  the  mem- 
brane higher  up  pulled  down  to  take  its  place.     Prof.  Weir 


HEMORRHOIDS   OR  PILES.  43 

thinks  the  subsequent  pain  is  less  than  after  Allingham's 
ligation,  but  it  is  difficult  to  see  why,  since  the  most 
exquisitely  sensitive  portion  of  the  integument  at  the  verge 
of  the  anus  is  pinched  up  in  a  circle  of  numerous  fine 
stitches,  while  its  sensory  nerve  supply  is  not  cut  olf  as  in 
Allingham's  method.  Prof.  "Weir's  six  cases  are  perhaps  not 
enough  to  settle  this  question. 

At  this  distance  we  are  not  able  to  ascertain  whether 
there  are  any  mistakes  in  Mr.  Whitehead's  enthusiastic 
claim  to  entire  exemption  from  the  accidents  known  to  be 
common  elsewhere  after  excision  of  internal  piles,  but  we 
think  caution  should  be  for  the  present  observed.  In  the 
United  States  some  very  disastrous  results  have  followed 
the  operation.  Prof.  AVeir  facilitates  the  separation  of  the 
piles  and  mucous  membrane  from  the  internal  sphincter  by 
dissecting  to  the  upper  limit  at  one  spot  first,  and  then  with 
the  nail  or  blunt  point  of  the  scissors  peeling  around  in  a 
circular  direction.  Allingham  recognizes  some  of  the  objec- 
tions to  the  method,  but  has  tried  it  and  even  invented  a 
complicated  four-armed  forceps  to  hold  the  mucous  mem- 
brane during  the  dissection.  He  diminishes  the  risk  of 
haemorrhage  by  passing  a  needle  and  ligature  through  the 
cut  edge  of  the  skin  and  through  the  mucous  membrane 
from  the  external  side  above  each  principal  pile  and  thence 
around  the  base  of  the  pile  and  doAvn  through  the  skin 
again,  and  tightens  it,  thus  clamping  the  artery  of  each 
principal  pile  to  the  skin  by  the  knot,  and  compressing  its 
nutrient  artery. 

The  objections  which  will  occur  to  every  one  are  these: 
1.  There  is  a  great  difference  in  patients  about  the 
liability  of  arteries  closed  by  torsion  to  untwist  their  fibres 
under  the  arterial  blood  pressure,  and  resume  li£emorrhage. 
If  this  occurs,  the  row  of  fine  stitches  set  in  a  tender  mucous 
membrane  is  not  adequate  resistance  against  the  force  of 
arterial  blood.  Haemorrhage  will  not  be  common,  but  accord- 
ing to  general  experience  in  other  operations  at  this  part. 


44  RECTAL   AND   ANAL   SURGERY. 

it  seems  nearly  incredible  that  it  should  not  sometimes 
occur. 

2.  According  to  the  experience  both  of  Prof.  Weir  and 
of  Mr.  Whitehead,  union  by  first  intention  will  not  always 
take  place,  and  if  it  does  not,  a  circular  ulcer,  and,  after  it,  a 
contracting  circle  of  cicatrix  will  surround  the  orifice.  In 
such  cases  it  is  impossible  to  see  why  stricture  may  not 
occasionally  occur,  precisely  as  it  does  sometimes  where  a 
surgeon  incautiously  removes  in  other  operations  a  complete 
zone  of  mucous  membrane  at  the  same  place. 

All  things  considered,  it  is  an  operation  of  great 
severity,  and  some  danger,  and  ought  not  to  be  performed 
except  in  a  few  peculiar  cases,  since  safer  and  milder 
methods  have  almost  a  perfect  certainty  of  success. 


CHAPTER     IV. 

PEOCTITIS    OR     INFLAMMATION    OF    THE 
RECTUM. 

Proctitis  or  inflammation  limited  to  the  rectum  is  as 
distinctly  a  clinical  entity  as  colitis,  typhilitis,  duodenitis  or 
any  localized  affection  of  the  intestinal  tube.  It  deserves  to 
be  considered  entirely  apart  from  periproctitis  or  cellulitis, 
with  which  it  has  little  in  common. 

Causes. — Mechanical  irritation  is  often  the  direct  cause 
of  an  inflamed  condition  of  the  lower  bowel.  After  wounds 
and  contusions  there  is  apt  to  be  slight  muco-purulent  dis- 
charge and  some  degree  of  tenesmus  lasting  for  a  few  days. 
This  is  equally  true  of  operations,  particularly  the  removal 
of  haemorrhoids  and  forcible  dilatation.  When  the  sphincter 
has  been  forcibly  dilated  an  increased  sensitiveness  of  the 
organ  almost  always  follows  for  a  certain  length  of  time,  so 
that  whatever  material  has  descended  to  within  a  short 
distance  of  the  anus  is  likely  to  be  evacuated  suddenly. 

To  this  is  probably  due  the  fact  that  forced  dilatation 
of  the  sphincter  is  reputed  to  have  a  powerful  influence  in 
curing  chronic  constipation. 

Foreign  bodies  are  not  very  rarely  introduced  into  the 
rectum  by  accident  or  design.  Chilcb-en  and  persons  of 
perverted  instincts  frequently  thrust  objects  of  considerable 
size  into  the  anus.  When  from  their  shape  or  size  these 
cannot  be  expelled  in  the  natural  motions  great  irritation  is 
likely  to  ensue,  sooner  or  later  leading  to  perforation  of  the 
bowel  and  periproctitis.  Improper  or  too  frequent  use  of 
syringes  may  also  cause  considerable  proctitis.  When  the 
faeces  contain  angular  or  sharp-pointed  objects  the  rectum  is 

45 


46  RECTAL   AND   ANAL   SURGERY. 

more  likely  to  suffer  laceration  than  tlie  bowel  higher  up 
because  of  the  indurated  and  inspissated  character  of  the 
material  which  must  cause  such  objects  to  be  pressed  more 
strongly  in  contact  with  the  membranes.  Such  objects  are 
fishbones,  nut-shells  and  occasionally  even  coins,  pins  and 
needles  which  have  been  swalloAved.  Certain  kinds  of  food 
which  undergo  putrefactive  changes  frequently  cause  slight 
transient  catarrh  of  the  rectum.  Among  such  articles 
are  Brie  and  Limburger  cheese  and  game  too  long  kept. 

The  influence  of  cold  is  occasionally  felt  in  producing 
slight  irritations  here  as  in  other  mucous  membranes. 

In  parturition  there  is  sometimes  transient  acute  proc- 
titis.     It  may  also  result  from  the  presence  of  oxyurides. 

Among  prostitutes  the  practice  of  sodomy  is  a  frequent 
cause  of  proctitis  apart  from  the  effect  of  contagion.  The 
sphincter  also  becomes  relaxed  or  torn.  Gonorrhoeal  and 
syphilitic  proctitis  are,  however,  not  generally  the  effects  of 
sodomy  but  of  infection  from  other  parts,  or  of  constitutional 
disease.  Women,  as  is  well  known,  are  the  usual  victims  of 
gonorrhoea  of  the  rectum. 

Dipliiheria  of  the  rectum  as  described  by  Trousseau  is 
certainly  a  form  of  proctitis  rarely  noticed  in  America.  It 
does  not  occur  as  a  primary  affection  but  in  conjunction 
with  the  same  disease  in  the  throat  and  only  in  cases  of 
severe  general  poisoning. 

Tuberculosis  of  the  rectum  has  not  so  much  to  do  with 
proctitis  as  with  periproctitis  and  fistula  in  ano.  Another 
condition  favorable  to  the  production  of  proctitis  is  a  hsemor- 
rhoidal  condition  of  the  rectal  wall.  Verneuil  has  called 
attention  to  the  fact  that  the  veins  of  the  rectum  in  their 
upward  course  penetrate  the  muscular  layer  in  such  a  way 
that  they  are  constricted  with  each  contraction  of  the  bowel. 
Stasis  of  blood  and  engorgement  of  the  vessels  are  thus 
broug^ht  about  with  each  act  of  defecation.  A  condition  is 
set  up  not  unlike  that  seen  in  varicosities  of  the  lower  limbs, 
predisposing  to  oedema  and  indolent  ulceration  of  the  mem- 


PROCTITIS    OR   INFLAMMATION   OF  RECTUM.  47 

brane.    This  has  been  termed  by  Eokitansky  "  hsBmorrhoidal 
ulceration." 

Dyseniery  is  commonly  associated  with  some  proctitis. 
Many  cases  of  chronic  inflammation  and  ulceration  of  the 
lower  bowel  are  due  to  this  cause,  especially  in  hot  climates. 

Amyloid  disease  of  the  kidneys  is  sometimes  responsible 
for  inflammation  and  deofenerative  changes  in  the  mucous 
membrane.  Bartels  assigns  as  the  cause  of  this  the  degener- 
ation of  the  blood  vessels  in  tlie  lining  membrane. 

Follicular  disease  of  the  mucous  membrane  is  another 
cause  of  proctitis.  The  scattered  glands  of  the  large 
intestine  become  inflamed,  enlarged  and  finally  suppurate, 
discharging  each  a  sphacelus  and  leaving  small  rounded 
ulcers  upon  the  membrane.  It  is  uncertain  whether  these 
should  be  considered  as  a  cause  or  as  an  effect  of  catarrhal 
inflammation. 

Symptoms. — Acute  proctitis  gives  rise  to  symptoms 
not  wholly  unlike  those  of  dysentery.  It  is  now  held  that 
the  rectum,  even  in  health,  does  not  act  as  a  receptacle  for 
any  length  of  time,  but  tends  normally  to  expel  its  contents 
very  shortly  after  they  are  received.  In  proctitis  this 
tendency  is  very  markedly  increased  and  exaggerated. 
While  there  may  be  no  true  diarrhoea,  the  faeces  and  gases 
are  expelled  spasmodically  almost  as  soon  as  they  reach  the 
rectal  pouch.  This  may  occur  without  the  patient's  con- 
sciousness, but  more  often  it  is  accompanied  by  slight  tenes- 
mus like  that  of  dysentery. 

An  increased  secretion  of  mucous  is  another  symptom 
of  acute  proctitis.  This  may  be  clear  or  streaked  with  blood, 
sometimes  it  is  expelled  in  small  gelatinous  masses  apart 
from  defecation.  More  or  less  irritation  of  the  skin  about 
the  anus  often  exists  as  a  result  of  the  irritatinor  discharges. 
This  is  much  more  likely  to  occur  in  the  gonorrhoeal  form. 

Swelling  of  the  mucous  and  submucous  tissue  is 
usually  present,  but  there  is  not  much  local  pain  except  the 
tenesmus  during  defecation.     The  oedema  often  causes  some 


48  RECTAL   AND   ANAL  SURGERY. 

protrusion  of  the  swollen  membranes,  a  condition  described 
by  Roser  as  "  ectropion  recti." 

Accompanying  all  forms  of  proctitis  there  may  be  more 
or  less  irritability  of  the  prostate  or  bladder  and  an  increased 
frequency  of  urination. 

Gonorrhoeal  proctitis  differs  little  in  its  general  features 
from  gonorrhoea  elsewhere.  Large  quantities  of  muco-pus 
are  discharged  during  the  height  of  the  inflammation,  which 
usually  lasts  from  two  to  four  weeks.  Microscopic  examin- 
ation will  show  the  presence  of  the  characteristic  microbe  or 
gonococcus  (Klein). 

Bumstead  and  Taylor  and  Neumann  have  proved  that 
chancroids  within  the  rectum  are  not  by  any  means  unusual. 
This  must  nearly  always  be  the  result  of  sodomy  rather  than 
of  auto-infection,  although  the  latter  is  possible,  as  by  the 
insertion  of  an  infected  finger  or  syringe  within  the  rectum. 
In  Neumann's  clinic  a  very  clearly  marked  case  of  chan- 
croidal ulcer  well  above  the  sphincter  was  observed  and 
described  in  1881.  The  patient  admitted  the  practice  of 
sodomy. 

True  chancres  of  the  rectum  and  anus  would  hardly  be 
noticed  by  the  patient.  Fournier  has  proved  their  frequent 
occurrence  both  within  and  outside  of  the  rectum. 

Condylomata  are  the  most  familiar  of  all  sy2:)hilitic 
manifestations  about  the  rectum.  They  are  essentially  like 
mucous  patches  or  papules  occurring  elsewhere  in  secondary 
syphilis  but  owe  their  peculiar  form  to  the  irritation  to  which 
they  are  constantly  subjected.  At  times  they  take  on  almost 
the  appearance  of  warts  or  vegetations.  In  the  folds  of  the 
mucous  membrane  of  the  anus  where  there  are  mucous 
patches,  there  is  often  a  tendency  to  the  formation  of  small 
rounded  ulcers  with  sharply  elevated  edges  [rhagades). 
The  subsequent  healing  and  contraction  of  these  ulcers 
produce  a  curious  folding  and  wrinkling  of  the  skin, 
described  by  Sir  James  Paget  as  a  true  characteristic  of 
syphilis  of  the  rectum. 


PROCTITIS    OR   INFLAMMATION   OF  RECTUM.  49 

Another  form  of  syphilitic  proctitis  is  often  met  in 
■which  there  is  a  diffused  thickening  of  the  whole  rectal 
wall,  causing  it  to  become  harder  than  natural  and  some- 
what oedematous.  Fournier  describes  this  condition — under 
the  name  ano  rectal  sijpliiloma — as  a  hyperplasia  followed 
by  sclerosis  of  the  membranes  so  that  they  ultimately  become 
contracted  and  fibrous. 

Tertiary  syphilis  of  the  rectum  begins  by  the  deposit 
of  gummata  upon  the  membrane  in  the  form  of  smooth, 
globular,  painless  tumors.  These  run  the  usual  course  of 
such  deposits,  breaking  down  and  producing  rounded  ulcers 
which  coalesce  and  destroy  the  mucous  and  submucous 
tissue.  The  healing  of  these  ulcers  if  extensive  inevitably 
brings  on  stricture  of  the  rectum.  There  is  little  doubt 
that  tertiary  syphilis  of  the  rectum  is  very  common.  That 
it  is  not  oftener  seen  in  its  earlier  stages  is  due  to  the 
painless  character  of  the  affection  and  its  remote  location. 
Accompanying  iilcerative  proctitis,  of  a  syphilitic  or  any 
form,  there  is  of  course  some  mucous  and  purulent  dis- 
charge, which,  however,  may  not  attract  much  attention. 

There  is  not  infrequently  amyloid  degeneration  of  the 
rectal  wall  in  advanced  syphilis.  This  results  from  a 
similar  condition  of  the  intestine  above.  Alliugham  applies 
the  term  "lupoid"  or  "rodent"  ulceration  to  what  is 
probably  identical  Avith  lupus  in  other  parts  of  the  body, 
though  occurring  often  in  persons  not  in  advanced  years. 
Some  cases  of  extreme  destruction  have  been  observed  from 
this  disease  in  which  the  rectum  was  extensively  undermined 
and  the  bowel  left  "hanging  loose  and  ragged"  "like  the 
torn  sleeve  of  a  coat." 

Treatment  of  Proctitis. — Acute  proctitis  is  commonly 
a  transient  affection  when  due  to  extension  from  the  same 
condition  higher  up  and  calls  for  no  separate  treatment. 

When  due  to  mechanical  irritation,  local  interference 
except  to  remove  foreign  substances  is  often  unnecessary, 
the  inflammation  subsiding  quite  rapidly  when  rest  in  bed 


50  RECTAL   AND   ANAL  SURGERY. 

is  maintained.  The  local  use  of  anodynes  and  antiseptics  in 
the  form  of  suppositories  is  often  to  be  recommended, 
however.  To  ensure  rest  the  bowel  should  be  kept  evacuated. 
A  recent  British  writer  advises  against  enemata  for  this 
purpose  on  account  of  the  danger  of  spreading  infection 
upward.  This  danger  can  only  exist  in  special  cases.  Small 
injections  of  hot  water  are  decidedly  soothing  and  help  to 
control  the  inflammation,  at  the  same  time  cleansing  the 
rectum. 

For  tenesmus  it  is  well  to  use 

Mucilage  of   starch ^ij 

Tr.  opii x-xxx 

Inject  slowly. 

An  anodyne  antiseptic  of  great  value  is 

Iodoform 3i 

Ext.  belladon gr.  v 

Pulv.  opii gr.  X 

01.  theobrom q.s. 

M.  Ft.  Suppositories  No.  xii 

Boric  and  carbolic  acid  are  slightly  irritating  and  cause 
some  smarting  of  the  anus.  Corrosive  sublimate  is  not  a 
suitable  antiseptic  for  use  within  the  rectum  on  account  of 
its  irritating  properties  not  less  than  its  poisonous  properties 
when  absorbed. 

Chronic  proctitis  is  best  treated  by  the  free  use  of  hot 
water  to  cleanse  and  soothe  the  congested  membrane.  The 
hot  douche  is  also  advised  after  certain  injections  to  remove 
them  and  prevent  their  absorption. 

Thus,  for  chronic  proctitis 

Argent,  nit g^-  v. 

Aq.  dest 3ij 

may  be  injected  and  removed  by  a  subsequent  enema. 

While  the  local  effect  of  this  solution  ought  to  be  favor- 
able, its  immediate  removal  probably  prevents  any  decided 
action.     Neither  are  we  inclined  to  recommend  for  general 


PROCTITIS   OR   INFLAMMATION   OF  RECTUM.  51 

use  within  the  rectum  any  solution  which  safety  requires 
shoukl  be  washed  out  again.  It  is  not  always  possible  to 
know  how  far  injections  are  carried  and  whether  they  are 
subsequently  removed  or  not  by  washing  with  additional 
water. 

The  following  by  Ball  is  of  use  where  the  discharges 
are  fetid: 

Liq.  carbonis  detergent 3ii 

Tr.  kramerise 3iv 

Mucil.  amyli q.  s.  ad  ^iv 

M.  Liq.  Inject  3!  morning  and  night. 

A  solution  of  bismuth  with  mucilage  of  starch  is 
recommended  as  a  safe  local  application,  viz: 

Liq.  bismuth 3i 

Mucil.  amyli ^vi 

It  is  well  to  remember  that  glycerine  if  used  freely  in 
the  rectum  will  of  itself  be  decidedly  irritating.  Mucilage 
of  starch  is  therefore  better  than  any  preparation  such  as 
"glycerite  of  starch." 


CHAPTER     V. 
DISEASES    OF    THE    SACCULI    HOENERI. 

Fortunately  the  sacculi  are  not  very  prone  to  disease, 
except  as  they  participate  in  inflammations  of  adjacent  parts. 
Still  they  occasionally  give  lodgment  to  small  foreign  bodies, 
which  may  cause  ulcers  of  a  septic  character,  and  which  by 
their  location  close  to  the  zone  of  greatest  nervous  supply  of 
the  rectum  may  give  origin  to  extensive  and  distressing 
reflex  symptoms,  even  in  distant  parts  of  the  body. 

At  the  present  time  special  attention  has  been  directed 
to  the  sacculi  by  the  traveling  "pile  doctors"  who  have 
gotten  the  idea  that  the  sacculi,  or  "pockets"  as  they  com- 
monly call  them,  are  never  healthy,  but  are  themselves  a 
disease  in  their  very  nature,  and  that  they  must  always  be 
destroyed.  As  the  patient  cannot  see  the  sacculi  and  is 
unable  to  deny  their  diseased  nature,  he  is  at  the  mercy  of 
the  traveling  man  and  gladly  pays  a  high  fee  to  have  such 
dangerous  organs  split  open  and  destroyed.  The  sacculi 
are  described  in  Chapter  I.,  but  we  may  be  allowed  to  refer 
again  briefly  to  them,  since  noisy  itinerants  are  making  use 
of  them  so  extensively  in  their  trade  and  doing  injury  to 
thousands  of  deluded  patients. 

The  anatomy  of  the  organs  referred  to  is  given  by 
various  authors,  both  old  and  new,  and  we  have  been  at  the 
trouble  to  verify  their  descriptions  and  drawings,  by  new 
dissections  of  our  own,  assisted  by  Prof.  Billings,  of  the 
Chicago  Medical  College.  In  a  healthy  rectum  the  mucous 
membrane  just  above  the  verge  of  the  anus  is  traversed  by 
minute  branching  ridges,  enclosing  slight  concavities  of 
varied  shapes  and  sizes.    If  a  healthy  rectum  from  a  cadaver 

52 


DISEASES   OF  THE  SACCULI  HORNERI.  53 

be  laid  open  and  spread  out  after  the  rigor  mortis  is  past, 
the  ridgfes  will  be  found  to  curve  and  interlace  in  all  direc- 
tions  and  to  be  only  faintly  visible,  but  if  examined  during 
life  it  will  be  seen  that  the  action  of  the  sphincter  ani 
presses  them  together  laterally,  so  that  the  ridges  run  in  a 
more  perpendicular  direction,  and  receive  the  name  of 
colummv  recti.  The  framework  of  these  little  ridges  does 
not  consist  of  mere  folds  of  mucous  membrane,  as  some 
authors  state.  They  are  reticulate  bands  of  muscular  and 
connective  tissue,  and  the  delicate  mucous  membrane,  when 
healthy,  can  be  made  to  glide  freely  over  them. 

These  little  columns  are  inserted  at  their  lower  extrem- 
ities into  the  verge  of  the  anus,  and  at  that  point  one  is 
often  connected  to  its  nearest  fellows  by  webs  of  mucous 
membrane,  making  the  "pockets"  above  mentioned,  which 
wefe  long  ago  named  the  scicculi  Horneri,  by  anatomists, 
after  the  distinguished  Dr.  Horner.  They  are  figured  by 
various  authors,  and  good  illustrations  may  be  seen  in 
Smith's  Anatom.  Atlas,  fig.  331,  page  112;  Esmarch's 
recent  w^ork  on  the  Rectum,  and  in  Allen's  Anatomy,  plate 
101.  They  are  much  less  distinct  in  some  persons  than  in 
others,  but  in  all  perfectly  healthy  rectums,  where  the 
mucous  membrane  is  normally  thin  and  elastic,  the  lower 
ends  of  the  grooves  between  the  columns  will  show  hollows, 
which  sometimes  are  of  considerable  depth,  but,  even  if 
shallow,  a  little  traction  with  a  blunt  hook  readily  makes 
them  assume  the  form  of  sacculi  or  "  pockets,"  well  adapted 
to  deceive  an  examiner  who  is  not  aware  of  the  elasticity  of 
the  membrane.  In  perfectly  sound  rectums  the  membrane 
covering  the  reticulated  ridges  and  lining  the  hollows  is 
exceedingly  elastic  and  distensible,  to  allow  of  the  requisite 
dilatation  during  the  expulsion  of  the  fsecal  mass.  The 
sacculi  and  other  hollows  of  the  reticulated  zone  contain  a 
reserve  of  tenaceous  mucus,  which  is  pressed  out  as  the 
faeces  descend,  and  lubricates  the  descending  mass.  When 
carefully  examined  in  healthy  organs,  the  sacculi  show  no 


54  RECTAL   AND   ANAL  SURGERY. 

trace  of  disease,  but  are  lined  with  a  perfectly  normal  and 
beautifully  delicate  mucous  membrane,  which  moves  freely 
on  the  parts  beneath,  and  stretches  readily  in  any  direction. 
The  claim  that  they  are  "diseases"  is  simply  absurd. 
However,  these  reservoirs  of  mucus,  like  the  analagous 
pockets   in   the   tonsils,  occasionally  become  inflamed    and 

even  ulcerated,  and  then  may  require 
clipping  out,  as  was  long  ago  stated 
by  Henry  H.  Smith,  of  Philadelphia, 
as  well  as  by  the  elder  Gross,  and  by 
Ashhurst  and  others.  Berry  seeds 
and  other  minute  objects  occasion- 
ally, but  not  often,  lodge  in  them. 

Between  the  lower  ends  of  the 
grooves  are  frequently  found  a  few 
papillae,  reminding  one  of  the  anal- 
ogous carunculcB  myrtiformes  of  the 
vagina,  though  they  are  usually 
se^ro^n^'S'the^JrhorrxSJi"   Smaller.    They  show  a  healthy  struc- 

cut  shows  the  reticulated  arrange-     ,  •  .  ^  j 

ment  under  post-mortem  relaxa-  turC  lU  mOSt  CaseS,  and  are  SUppOSBQ 
tion.     The   lower   cut   shows   the 

same  parts  compressedlaterally  by  to  be  tactile  OrgaUS,  WhOSC  UerveS 
the  contraction  of  the  sphincter.  _  i  •  i 

c.  c.  c.  coiumnie  recti,  s.  Dotted   commuuicate  rcflex  impulscs  to  the 

curves,   showing   the   position   of  J- 

sfwcuu  Horneri  between  the  bases   exDulsorv  muscles  engaged  iu  defe- 

of  the  columns.     P.  P.  Papulae.  r  J  O    o 

cation.  These  little  papillae  with  the 
adjacent  "  pockets "  constitute  an  important  part  of  the 
harvest  field  of  the  itinerants. 

The  following  letter,  from  the  distinguished  Prof. 
Henry  H.  Smith,  of  Philadelphia,  shows  the  error  of  the 
claim  that  the  so-called  "pockets"  are  a  new  thing  in 
science : 

PmLADELPHiA,  May  4,  1887. 

Prof.  E.  Andrews: 

Dear  Sir:  "  The  rectal  pouches  "  (  "Sacculi  Horneri "  )  are  a 
normal  structure,  intended  to  hold  mucus,  which  is  forced  out  in 
defecation,  to  lubricate  the  margin  of  the  anus,  and  protect  it 
from  hardened  faeces.     In  1792  Physick  called  attention  to  them 


DISEASES   OF   THE  SACCULI  HORNERI.  55 

(see  American  Encyclop.  of  Med.  and  Snrg'y.  article  '•  Anns,"  by 
Coates;  see  also  Smith's  Operat'e  Surg.,  Yol.  II.,  p.  590,  1863), 
for  the  operation  sometimes  required.  For  their  structure,  see 
Horner's  Special  Anatomy,  Vol.  II.,  p.  46,  1851;  see,  also,  Ameri- 
can Jour.  Med.  Science,  Vol.  XVII.,  N.  S.,  p.  410,  1849;  Winslow 
(Vol.  II.,  p.  149)  described  these  pouches  in  1749.  In  "  Smith's 
Anatomical  Atlas,"  published  in  1844,  by  Lea,  you  will  find  in 
figure  331,  page  112,  an  accurate  drawing  of  the  "  Sacculi 
Horneri,"  which  I  guarantee  to  be  correct. 

'•  Truly  yours, 

"HENRY  H.  SMITH." 

The  rise  and  progress  of  the  itinerant  is  usually  this: 
He  buys  for  fifty  or  a  hundred  dollars  from  the  owner  of 
one  of  the  "Systems  of  Kectal  Surgery"  a  little  poverty- 
stricken  box  of  instruments,  containing  a  speculum,  a  blunt 
hook,  a  hypodermic  syringe,  and  a  few^  other  things.  The 
box  also  contains  a  little  pamphlet  telling  him  how  to  use 
the  instruments  on  piles,  ''  pockets,"  fistulse,  and  ulcers.  AVith 
the  box  he  receives  a  mixture  of  carbolic  acid,  some  salves, 
washes,  etc.,  wdth  the  gracious  privilege  of  buying  more  of 
them  at  a  tremendous  price  of  the  owner  of  the  "  System  " 
when  the  stock  is  exhausted.  He  is  not  always  allowed  to 
know  their  composition. 

Inserting  his  speculum  into  a  patient  the  fully  developed 
traveling  quack  ahvays  finds  "pockets."  If  they  are  not 
there  he  makes  them  by  pressing  his  blunt  hook  into  the 
delicate  membrane.  A  fold  being  thus  caught  he  splits  it 
down  with  a  Sims'  knife,  and  then  finishes  the  operation  by 
a  forced  dilatation  of  the  sphincter,  and  by  collecting  his 
fee.  The  cutting  is  trivial,  and  including  only  a  few  of  the 
sacculi,  it  does  not  seriously  injure  the  patient,  but  the  indis- 
criminate forced  dilatations,  though  useful  in  some  cases, 
leave  prolonged  bad  results  in  others. 

However,  as  before  stated,  the  sacculi  may  be  really 
diseased.  Hence  it  is  often  necessary  carefully  to  examine 
the  entire  circle  of  them,  when  obscure  reflex  distresses  are 


56 


RECTAL   AND   ANAL   SURGERY. 


found  harrassing  the  })ntient.  For  this  purpose  place  the 
patient  in  Sims'  position  in  a  good  light  and  insert  any  good 
speculum.  Carefully  try  the  lower  ends  of  all  the  grooves 
between  the  columns  of  Morgagni  with  the  point  of  a  Sims' 


r- 


<s 


Fig.  23. — Sims'  Blunt  Hook. 


blunt  hook.  If  any  sacculus  is  swollen,  suppurating,  or 
excessively  sensitive,  it  is  best  to  snip  it  out  with  curved 
scissors  as  recommended  long  ago  by  Prof.  Henry  Smith,  or 
else  to  split  it  downward  with  a  probe-pointed  bistoury. 


Fig.  24. — Cukved  Scissobs. 

The  incisions  should  not  be  deep,  and  a  little  boric  acid 
or  iodoform  should  be  dusted  into  the  wound.  The  number 
of  seriously  diseased  sacculi  found  by  any  honest  examiner 
will  not  be  large,  but  the  few  discovered  are,  on  account  of 
their  nervous  relations,  prolific  in  distressing  reflexes. 


CHAPTER     VI. 
ABSCESS    AND    SINUS;    FISTULA    IN    ANO. 

Suppuration  in  the  cellular  tissue,  around  the  rectum, 
as  well  as  in  the  walls  of  the  intestine  itself,  and  in  the 
marginal  region  of  the  anus,  is  so  frequent  an  occurrence 
that  it  may  be  said  to  be  responsible  for  thirty  or  forty  per 
cent,  of  all  troubles  about  the  anus.  It  may  be  doubted 
whether  the  experience  of  the  profession  at  large  would 
conform  to  that  of  Allingham,  who  found  that  two-thirds 
of  all  recorded  rectal  operations  at  St.  Mark's  Hospital, 
London,  Avere  cases  of  fistula  in  ano.  It  is  quite  likely  that 
haemorrhoids  are  a  more  common  affection  in  the  practice  of 
most  surgeons.  Next  in  frequency,  however,  without  doubt, 
would  come  the  various  forms  of  abscesses  and  their  sequelae, 
sinuses  and  fistulae. 

Sinuses  about  this  region  are  much  more  commonly 
presented  to  the  surgeon  than  abscesses  in  the  acute  stage, 
and  call  for  much  more  skill  and  patience  in  their  treatment. 
Not  every  abscess  in  the  vicinity  of  the  anus  necessarily 
produces  a  fistula.  The  fact  must  have  come  under  the 
observation  of  all  who  have  treated  many  cases  of  such 
troubles,  that  such,  collections  of  pus  do  often  break  or  are 
opened  externally,  and  heal  as  promptly  as  those  in  any 
other  part  of  the  body.  On  the  other  hand,  many  cases  refuse 
to  heal  completely,  and  a  sinus  remains  for  months  or  years, 
which  ultimately  requires  surgical  interference  for  its 
removal.  Early  incisions  into  pus  collections  about  the 
rectum  undoubtedly  tend  to  prevent  the  latter  result. 

Those  superficial  abscesses  which  sometimes  form  at  the 
anal  margin  have  no  tendency  to  produce  fistulas,  and  require 

57 


58  RECTAL   AND   ANAL   SURGERY. 

no  especial  description.  Tliey  are  diie  in  most  cases  to 
inflammation  in  some  obstructed  follicle  or  gland  which  has 
become  irritated  in  the  various  movements  of  defecation, 
sitting,  riding  or  walking.  Suppuration  in  an  inflamed 
hsemorrhoid  may  also  cause  small  superficial  abscesses. 
These  minor  forms  should  be  treated  like  ordinary  boils  in 
other  parts,  by  fomentations,  anodynes,  and  early  incisions. 

Deep  abscess  at  or  near  the  rectum  is  a  more  common 
and  serious  afl^ection.  Tlie  large  amount  of  loose  cellular 
tissue,  especially  behind  the  rectum,  allows  very  large 
collections  to  accumulate  before  external  pointing  occurs; 
and  as  such  abscesses  connect  with  the  bowel,  they  may  be 
found  distended  by  gas  and  fsecal  matter,  and  in  a  highly 
septic  condition. 

The  causes  of  ischio-rectal  abscesses  are  not  always 
evident.  The  presence  of  foreign  bodies  in  the  rectum,  the 
irritation  produced  by  instruments  such  as  syringes,  or  by 
falls,  blows  and  other  traumatic  influences  are  often  found 
to  be  exciting  causes.  Perhaps  more  often  no  direct  history 
of  injury  is  present,  and  the  case  must  be  classed  as 
idiopathic.  Extravasation  of  the  intestinal  contents  through 
some  ulcerated  portion  is  supposed  to  be  the  cause  in  many 
instances.  This,  however,  is  largely  a  matter  of  conjecture, 
for  it  is  not  usually  possible  to  determine  whether  the  open- 
ing into  the  rectum  is  a  cause  or  only  an  effect  of  the 
suppuration  of  the  connective  tissue  outside  of  it.  The 
tubercular  element  in  causation  seems  to  have  as  decided  an 
influence  in  this  as  in  other  suppurative  troubles.  There  is  a 
marked  tendency  to  the  occurrence  of  abscess  and  fistula  in 
phthisical  patients  which  has  long  been  recognized,  and 
which  has  given  rise  to  some  difference  of  opinion  as  to  the 
propriety  of  operative  measures  in  such  cases. 

The  local  symptoms  which  mark  the  formation  of  such 
abscesses,  are  oedema,  pain  and  often  a  localized  red  spot  to 
one  side  of  the  anus.  Sometimes  the  abscess  takes  a  horse- 
shoe form,  and  presents  upon  the  skin,  both  sides  of  the 


ABSCESS  AND  SINUS;   FISTULA    IN  ANO.  59 

anus,  having  half  encircled  the  rectum  upon  its  posterior 
side.  Great  tenderness  and  swelling  accompanies  deep 
abscess  in  this  region,  even  before  much  redness  appears 
externally. 

Examination  bv  the  rectum  reveals  a  thickenino:  of  the 
parts  posteriorly,  and  upon  one  or  both  sides.  This  exam- 
ination is  often  too  painful  to  be  borne  by  the  patient. 
When  fluctuation  is  detected  by  the  finger  in  the  bowel,  and 
the  abscess  shows  no  sign  of  appearing  externally,  there  is 
no  impropriety  in  incising  it  through  the  rectal  wall. 
Theoretically  it  would  be  much  better  to  have  such  an  open- 
ing externally  only,  but  in  practice  an  abscess  opened  by  an 
internal  incision  will  often  heal  kindly  and  promptly.  As  a 
rule,  the  swollen  and  oedematous  condition  of  the  parts  about 
the  anus  gives  an  indication  for  early  seeking  the  pus  with 
an  exploring  needle  or  lancet  extej-nally.  Too  much  import- 
ance cannot  be  attached  to  the  necessity  of  early  interference 
in  order  to  anticipate  extensive  burrowing  of  the  pus,  per- 
foration of  the  bowel,  and  the  formation  of  extensive  sinuses, 
and  ultimately  a  fistula.  It  is  well,  therefore,  to  make  early 
and  deep  incisions  into  the  thickened  and  inflamed  tissue, 
since  when  much  oedema  has  occurred  there  is  almost 
certainly  pus  present,  and  palliative  measures  result  only  in 
loss  of  time. 

Abscesses  j^roperly  drained  and  antiseptically  dressed 
will  quite  fi-equently  close  in  a  week  or  two,  without  the 
formation  of  a  fistula.  The  use  of  a  drainage  tube  is  neces- 
sary only  in  large  abscesses,  or  in  case  the  incision  be  small 
in  size.  The  tube  may  be  shortened  from  day  to  day,  and 
removed  finally  within  the  first  week. 

Fistula  in  Ano. — AUingham  reports  196  cases  of  ab- 
scess about  the  rectum,  of  which  151,  or  more  than  three- 
fourths,  resulted  finally  in  fistul?e.  When  once  established, 
a  fistula  has  no  tendency  to  heal  spontaneously,  and  may 
therefore  be  considered  a  suitable  object  in  nearly  all  cases 
for  surgical  interference.      Properly  speaking,  a  complete 


60 


RECTAL   AND   ANAL  SURGERY. 


fistula  is  a  sinus  leading  from  within  the  rectum  to  an  open- 
ing- on  the  skin  more  or  less  remote  from  the  anus.  There 
are,  however,  cases  in  which  the  internal  orifice,  if  any 
existed,  has  closed,  or  cannot  l)e  discovered  by  the  probe. 
These  are  termed  blind  external  fistulas    They  require  much 

the    same    treatment    as    those 
™  which    are  complete.     A  blind 


internal  fistula  is  one  which  has 
an  internal,  but  no  external, 
opening.  Such  a  sinus  has  a 
tendency  to  become  a  complete 
fistula  by  ulceration  through  the 
external  integument.  Occasion- 
ally cases  will  be  met  with  in 
which  there  is  a  recurrence  of 
acute  abscesses  which  break 
externally,  and  heal  for  a  time. 
These  are  often  due  to  the  exist- 
ence of  a  blind  internal  fistulous 

tract,  which  becomes   the  receptacle  of  foreign  substances 

from  the  bowel. 

The  causes  of  fistula  have  been  mentioned  under  the 

head  of  abscess,  the  disease  itself   being   but   the  chronic 

stage  of  that  affection.     Secondary  sinuses  or  diverticula  are 


Fig.  25.- -Fistula  Tkavebsed  by 
Peobe.     \^Esmarch.^ 


Fig.  26. — Intebnal  Incomplete 
Fistula.     \  Esmarch.^ 


Fig.  27. — External  Incomplete 
Fistula.     {Esmarch.'] 


usually  present  in  old  fistulse.  These  add  much  to  the  diffi- 
culty of  diagnosis,  and  to  the  severity  of  operative  measures. 
A  form  to  be  noted  is  the  "horse-shoe  fistula,"  so  called,  in 
which  the  sinus  surrounds   the  rectum  upon  its    posterior 


ABSCESS  AND   SINUS;   FISTULA   IN  ANO. 


61 


half,  and  extends  equally  upon  the  two  sides,  thus  under- 
mining the  cellular  tissue  for  about  one-half  the  circumfer- 
ence of  the  bowel. 

The  symptoms  of  hstula  are  not  easily  overlooked. 
Little  pain  is  present,  as  a  rule,  the  chief  discomfort  to  the 
patient  being  the  slight  discharge  which  is  kept  up  from  the 
sinus  as  long  as  it  remains  unhealed.  This  is  not  of  itself 
sufficient  to  be  exhausting,  and  does  not  prevent  or  interfere 
with  ordinary  occupations,  so  that  many  patients  have  had 
fistuljB  for  years  and  been  conscious  of  no  serious  ailment. 
The  annoyance  of 
the  discharge  is 
such  that  most 
persons  are  earn- 
estly desirous  of 
getting  rid  of  the 
trouble,  and  are 
willing  to  undergo 
an  operation  for 
its  removal.  The 
diagnosis  is  only 
difficult  in  distin- 
guishing different 
varieties.        There 

can  be  no  mistaking  the  general  nature  of  the  trouble 
when  the  parts  are  superficially  examined.  A  urinary 
fistula  is  not  infrequently  taken  for  fistula  in  ano,  and 
operated  upon  with,  of  course,  no  benefit  to  the  patient. 
Much  care  should  be  taken  to  exclude  these  cases,  and  also 
those  of  deep  pelvic  or  lumbar  abscess,  which  sometimes 
point  near  the  anus.  The  writer  has  frequently  been  called 
upon  to  examine  cases  of  urinary  fistula  which  had  been 
divided,  under  the  mistaken  supposition  that  they  were  cases 
of  fistula  in  ano.  Urinary  fistulee  may  sometimes  break 
into  the  bowel  as  well  as  externally.  The  diagnosis  becomes 
in  such  cases  more  difficult,  but  the  antecedent  history  of 


Fig.  28. — Section  of"Hobse-Shoe  Fistula"  with 
Diverticula.    Feom  Authob's  Obsebvations. 


62  RECTAL   AND   ANAL   SURGERY. 

urethral  stricture,  or  some  urinary  affection,  will  serve  to 
clear  up  doubtful  points. 

The  examination  of  a  fistula  is  best  made  with  the 
patient  upon  the  side  opposite  the  one  affected,  or  in  the 
lithotomy  position.  If  a  probe  be  passed  into  the  sinus,  and 
the  left  forefinger  into  the  rectum,  the  latter  may  sometimes 
feel  the  point  of  the  instrument  projecting  into  the  bowel  at 
a  point  not  far  from  the  sphincter.  More  frequently,  how- 
ever, some  difficulty  is  experienced  in  finding  the  internal 
opening,  on  account  of  the  irregular  character  of  the  fistula 
and  its  numerous  pouches  (Fig.  28).  The  opening  is  not 
usually  at  the  highest  point  of  the  fistulous  tract,  but  is 
found  most  often  between  the  two  sphincters,  within  an  inch 
of  the  orifice. 

If  the  probe  be  carried  to  the  extremity  of  the  cavity 
and  swept  downward,  pressing  the  wall  of  the  gut  between 
it  and  the  forefinger  in  the  rectum,  it  will  often  find  the 
internal  opening  as  it  reaches  this  vicinity.  In  other  cases, 
a  slight  protuberance,  as  of  granulations,  will  indicate  to  the 
trained  finger  where  to  seek  for  this  orifice.  The  expedient 
of  injecting  milk  into  the  fistula,  and  watching  for  the  point 
of  its  appearance  through  a  speculum,  is  often  a  valuable  aid 
in  the  examination. 

Treatment  of  Fistula. — Operative  measures  for  the 
radical  cure  of  fistula  are,  upon  the  whole,  satisfactory  and 
free  from  risk.  The  operation  of  dividing  the  sphincters 
and  intervening  tissues  yields  such  good  results  as  to  leave 
little  to  be  desired,  unless  some  measures  can  be  devised 
of  superseding  the  use  of  the  knife  altogether.  Of  such 
measures  we  shall  speak  further  on.  When  the  cutting 
operation  has  been  decided  upon,  the  bowels  should  be 
emptied  by  laxatives  or  enemata,  and  the  parts  thoroughly 
cleansed  and  shaved.  If  an  internal  orifice  exists,  it  is 
simply  necessary  to  pass  a  director  through  this  into  the 
bowel,  and  bring  the  end  out  through  the  anus,  after  which 
the  tissue  upon  the  instrument  is  divided  by  a  curved  bis- 


ABSCESS  AND   SINUS;   FISTULA    IN  ANO. 


63 


toury.  Lateral  sinuses  and  diverticula  should  now  be  laid 
freely  open,  where  they  do  not  extend  too  far  from  the  anus, 
and  the  wound  packed  with  iodoform  gauze  or  lint,  covered 
with  antiseptic  cerate.  Vessels  of  much  size  should  be  liga- 
tured. As  a  rule  there  is  but  little  haemorrhage.  Those 
deep  sinuses,  which  sometimes  extend  to  far  distant  parts, 
as  into  the  thigh  or  buttocks,  cannot,  of  course,  be  laid  open 
in  their  entire  length.  These  will  heal,  however,  after  the 
division  of  the  sphincter  and  the  laying  open  of  the  principal 
sack  or  fistulous  tract. 

FistulsB  which  have  no  internal  opening,  or  in  which  it 


Fig.  29. — "  Royal  Bistouby"  with  which  Chief  Subgeon  Felix  cubed 
Louis  XIV.     [Esuiarch.] 

is  supposed  to  exist,  if  at  all,  high  up  in  the  bowel,  are  to  be 
treated  by  division  of  the  lower  inch  of  the  rectum  only. 
The  point  of  the  director  in  these  cases  must  be  thrust 
through  the  wall  of  rectum  at  a  point  not  much  over  an  inch 
from  its  external  orifice,  and  the  incision  made  as  before 
directed  when  the  internal  opening  already  existed.  The 
surgeon  may  rest  confident  that  that  part  of  the  sinus  above 
this  limit  will  rapidly  close  after  the  division  of  the  parts 
below,  and  at  the  same  time  be  free  from  anxiety  about  cut- 
ting the  peritoneum,  which,  in  inflamed  and  prolapsed 
conditions  of  the  rectum,  may  be  tightly  glued  to  the  wall 
of  the  gut  and  brought  somewhat  nearer  than  normal  to  the 
anal  orifice.     In  blind  internal  fistulse  the  reverse  procedure 


64  RECTAL   AND   ANAL  SURGERY. 

is  recommended,  except  that  no  director  is  usually  needed, 
the  sinus  being  divided  downward  and  laid  open  with  a 
curved,  blunt  bistoury  until  the  bottom  of  the  cavity  is 
reached  and  both  sphincters  are  divided.  Daily  dressings 
are  to  be  practiced  until  the  granulations  have  lined  the 
interior  of  the  cut  and  all  tendency  to  union  of  its  walls  has 
ceased.  A  probe  should  be  swept  through  the  cut  so  as  to 
insure  this,  and  the  wound  kept  open  by  some  form  of  lint 
or  gauze,  until  healing  from  the  bottom  has  taken  place. 

Hippocrates'  Method. — The  use  of  the  ligature,  as 
advised  by  Hippocrates,  has  been  revived  from  time  to  time, 
with  the  hope  of  avoiding  operative  measures.  Hippocrates 
employed  a  cord  into  which  horsehair  was  twisted.  This 
was  drawn  through  the  sinus  into  the  bowel,  and  the  two 
ends  tightened  outside  the  anus.  The  possibility  of  thus 
curing  a  fistula  by  the  gradual  cutting  through  of  a  ligature 
is  evident,  and  there  may  be  cases  in  which  the  method 
would  be  less  severe  than  that  by  incision.  It  is  open  to 
the  objection  that  only  simple  sinuses  can  be  managed  in 
this  way.  Those  fistulse  which  have  numerous  diverticula 
would  not  be  benefited  by  merely  closing  the  main  channel, 
as  new  abscesses  would  at  once  form. 

Elastic  ligatures  have  been  tried  with  success  in  treat- 
ing fistulse  by  this  method.  They  have  the  advantage  of 
cutting  more  steadily  and  continuously,  and  also  avoid  to 
some  extent  the  necessity  for  tightening  the  cord,  which  is  a 
painful  feature  of  daily  recurrence  with  the  inelastic 
ligature.  On  the  whole,  the  method  has  little  practical 
value,  and  in  its  present  form  is  not  likely  to  become  a 
favorite  one. 

Itinerant  Methods. — The  "  traveling  doctors,"  and  the 
resident  irregulars  found  in  the  cities,  have  developed 
sundry  methods  of  treating  fistulse  which,  though  consider- 
ably varied  in  details,  may  be  stated  about  as  follows  in 
general : 

First,  they  explore  the  fistula  with  probes,  some  claim- 


ABSCESS  AND   SINUS;   FISTULA    IN   ANO.  65 

ing  advantage  in  a  very  llexible  one.  Then  they  smear  the 
adjacent  skin  with  an  vingnent.  to  protect  it  from  the 
ii'ritating  applications  employed.  They  then  tlioroughly 
inject  every  part  of  the  fistnla  with  a  solution  of  hydrogen 
peroxide.  This  is  put  in  either  through  a  line  flexible 
catheter,  or  with  a  syringe  having  a  flexible  metal  pipe.  After 
the  froth  caused  by  the  peroxide  has  mostly  escaped,  some 
take  a  mixture  of  equal  parts  of  95  j^er  cent,  carbolic  acid, 
and  of  10  per  cent,  solution  of  cocaine  (probably  using 
alcohol  or  glycerine  to  complete  the  solution),  and  inject  ten 
or  fifteen  minims  into  the  remotest  parts  of  the  fistula. 
Instead  of  this  last  formula  "Brinkerhotf  System"  employs 
the  following  mixture  under  the  name  of  "  Ulcer  Specific: " 

Jt     Dist.  ext.  hamamelis fl.   3v. 

Liq.  fer.  subsulph fl.   "j. 

Acid  carbol.  cryst gr.   ij. 

Glycerinfe fl.    "ij- 

Misce.  Signe.  Inject  ten  or  fifteen  drops  deeply  into  the 
fistula,  and  press  the  track  of  the  fistula  with  the  finger,  to  force 
the  fluid  more  deeply  in. 

Many  itinerants  finish  the  operation  two  hours  later  by 
injecting  the  fistula  with  equal  parts  of  oil  of  eucalyptus 
and  glycerine,  and  putting  the  patient  strictly  to  bed  for 
two  days. 

It  will  be  observed  that  ev^ry  step  in  this  treatment 
consists  in  the  injection  of  some  vigorous  antiseptic.  No 
disciple  of  Lister  could  fight  it  out  on  that  line  more  per- 
sistently. A  few  of  them  prepare  the  fistula  for  injection 
by  scratching  or  scarifying  slightly  the  interior  with  a  probe 
carrying  a  jointed  scarifier,  which  projects  laterally  from  the 
tip  and  scratches  as  it  is  drawn  oiit. 

An  excellent  regular  surgeon.  Dr.  Matthews,  of  Louis- 
ville, has  systematized  this  latter  plan,  and  made  it  more 
energetic.  He  dilates  the  external  part  of  the  fistula  with  a 
long  laminaria  tent,  and  then  inserts  Otis'  iirethrotome  and 
both  dilates  and  scarifies  the  interior,  repeating  the  operation 

5 


66  RECTAL   AND   ANAL   SURGERY. 

as  often  as  needful.     He  does  not  speak  of  any  antiseptic 
injection,  but  claims  success  in  some  twenty  cases. 

The  truth  is,  that  anal  fistulae  have  a  natural  tendency 
to  recovery,  and  are  held  back  from  it  mainly  by  two  things: 

1.  The  unfavorable  effect  of  the  undrained  septic  tiuids 
within  the  sac. 

2.  The  tightness  of  the  external  opening,  which  pre- 
vents free  di'ainage,  and  keeps  the  sac  distended  with  this 
putrid  pus. 

It  is  demonstrated  by  Dr.  Matthews  on  the  one  hand, 
and  by  the  experiments  of  the  quacks  on  the  other,  that  by 
controlling  these  two  conditions,  many  cases  will  heal  spon- 
taneously. It  follows  that  among  the  thousands  of  patients 
subjected  to  cutting  operations  by  surgeons  for  this  disease, 
there  are  many  who  might  be  cured  by  much  milder  means. 


CHAPTER     VII. 

nSSUEE    OF    THE    ANUS;    OR    IREITABLE 
MARGINAL    ULCER. 

Fissure,  or  irritable  anal  ulcer,  may  be  defined  as  an 
ulcerated  crack  or  fold  at  the  muco-cutaneous  junction 
laying  bare  certain  nerve  fibres  and  giving  rise  to  spasmodic 
contraction  and  paroxysmal  pain  of  a  peculiar  character. 

It  is  commonly — and  correctly — asserted  tliat  this  is 
the  most  painful  of  rectal  diseases.  In  appearance  incon- 
spicuous, a  mere  innocent-looking  tear  across  "  Hilton's 
white  line,"  it  is  nevertheless  the  source  of  surprising  and 
intolerable  pain,  and  gravely  disordered  reflexes. 

Contrary  to  general  belief,  Bodenhamer  has  proved  that 
fissure  of  the  anus  was  described  by  ancient  writers.  Paulus 
iEgineta,*  a  Greek  writer  of  the  fourth  century,  has  given 
a  brief  but  adequate  account  of  the  disease.  iEtius  (Medici 
Grceci  contractce  ex  veteribus,  etc. — Tetr.  IV,  Serm.  II.,  Cap. 
Ill)  describes  fissures  along  with  condylomata. 

To  the  French  surgeons  we  are  indebted  for  nearly  all 
the  modern  investigations  of  the  disease  and  the  chief 
improvements  in  treatment.  The  celebrated  Ambrose  Pare, 
writing  about  1550,  describes  almost  as  clearly  as  any 
modern  writer,  the  spasmodic  coi^itraction  and  the  sharp  and 
burning  pain  associated  with  fissures  of  the  anus  and  uterus. -j- 

*  Fissures  are  occasioned  principally  by  hard  faeces,  and,  being  slow 
of  granulating  owing  to  their  callosity,  must  be  converted  into  recent 
ulcers  by  paring  (excoriating,  scarifying  or  incising)  them  with  the  nails, 
or  a  scalpel;  when  they  may  be  made  to  granulate  by  proper  applica- 
tions.— Lib.  Septem,  Cap.  LXXX. 

■f  Chapps  or  fissures  are  cleft  and  very  long  little  ulcers,  with  paine  very 
sharpe  and  burning,  by  reason  of  the  biting  of  an  acride,  salt  and  drying 
humour,  making  so  great  a  contraction  and  narrowness  in  the  fundament 
and  neck  of  the  wombe  that  scarcely  the  toppe  of  one's  finger  may  be 
put  into  the  orifice  thereof. — Eng.  Translation,  1634. 

67 


RECTAL   AND   ANAL   SURGERY. 


Another  early  French  writer — Lemonnier— has  given  what 
seems  an  adequate  account  of  the  affection,  comparing  it  to 
the  chapped  condition  produced  in  the  lips  and  knuckles  by 
exposure  to  cold.*  Sabatier  also  mentions  it  in  a  similar 
connection.  Molliere,  Gosselin,  Recamier  and  Boyer  sever- 
ally aided  in  the  investigation  of  this  disease.  The  last 
named,  especially,  brought  out  very  clearly  the  importance  of 
reflex  spasm  of  the  sphincter  as  a  symptom.  This,  rather 
than  the  fissure  itself,  he  held  to  be  the  primary  and  essen- 
tial feature  of  the  affection,  Maisonneuve  and  Dupuytren 
advocated  and  practiced  forcible  dilatation,  the  former  intro- 
ducing the  whole  hand. 

Among  English  writers  Curling  and  Syme  very  early 
advocated   the    French    ideas   of    treatment.       In    America 

stretching  as  a  means  of  cure 
was  strongly  advocated  in 
1864  by  Van  Buren,  who 
probably  obtained  the  idea 
from  the  same  sources. 

Causes. — ^The  predispos- 
ing causes  of  fissured  anus 
and  its  peculiar  train  of 
symptoms  lie  in  the  struc- 
tural arrangement  near  the 
anus  and  their  physiology, 
Fig.  30.-DIAGBAM  of  Neeve  Supply  especially  of  nerve  control. 
OF  Anus.    [After  Hilton.]  ^  ^.Qrd   is   therefore  neces- 

M.  Mucous  membrane.    C.  Skin.    S.  E.  Ex-  i       i  r,                  •    i            j. 

ternal   sphincter.     L.  Hilton's  "white  line."  Sary  aS  tO  the  SpeCial  auatomy 

S.  I.  Internal  pphincter.     N.  A  nerve  passing  £  i.\                j. 

between  the  sphincters,  and  emerging  at  the  OI  tne  partS. 

"white  line "  to  skin  about  anus.  tt-h            i               i                   n      i 

Milton  has  shown  that 
the  line  of  junction  of  the  skin  and  mucous  membrane  at 
the  anus  is  also  the  exact  line  which  separates  the  external 

*Les  ragades  ou  fissures  sont  les  petits  ulcferes  douloureux,  piquans  et 
sans  grosseur,  qui  suivent  la  langueur  des  rides  du  fondement,  et  qui 
resemblent  assez  h.  ces  engelures  oii  crevasses,  que  le  froid  produit  aux 
l^vres  et  aux  mains  pendant  I'hiver.  —  Lemonnier,  Traite  de  la  Fistule  de 
UAnus—ieSd. 


FISSURE   OF   THE   ANUS.  69 

from  the  internal  sphincter.  Tliis  is  marked  in  most  cases 
by  a  line  of  more  condensed  connective  tissue  constituting 
the  edge  of  the  fascia  and  known  as  "  Hilton's  white  line" 
(Fig.  30).  The  important  anatomical  fact  in  connection 
with  this  line  is  that  it  is  the  point  of  exit  of  the  branches 
of  the  pudic  nerve  which  descend  between  the  two  sphincter 
muscles  and  are  here  distributed  to  the  papillae  and  mucous 
membrane  of  the  anus. 

The  abundant  nerve  supply  of  the  mucous  membrane 
accounts  not  only  for  the  extreme  sensitiveness  of  the  part 
but  also  for  its  very  abundant  reflex  communications  with 
other  organs. 

Ball  shows  that  the  nervous  supply  of  the  rectum  is 
quite  analogous  to  that  of  the  bladder  in  Avhich  the  most 
sensitive  portion  of  the  organ  is  the  neck  and  outlet. 

Small  ulcers  about  the  anus  are  pajnful  or  not  in  pro- 
portion as  they  are  near  or  remote  from  this  particular  zone 
of  sensory  nerve  supply.  External  and  internal  ulceration 
which  do  not  involve  the  actual  meeting  line  of  skin  and 
mucous  membrane  have  none  of  the  characters  of  true 
fissure.  The  most  plausible  theory  as  to  true  fissure  sup- 
poses that  these  nerve  filaments  are  actually  laid  bare  by  the 
ulceration,  something  as  they  are  in  figure  80  by  dissection, 
so  as  to  be  subject  to  actual  contact  with  each  motion  of  the 
bowels. 

Upon  this  supposition  it  is  not  difficult  to  explain  dis- 
proportionate symptoms  which  sc^  small  a  lesion  produces. 

We  are  thus  prepared  to  understand  why  reflex  spasm 
of  the  sphincter  is  so  constant  and  important  a  sign  of 
this  disease  and  how  other  and  wider  reflexes  are  to  be 
accounted  for;  such,  notably,  as  urinary  retention,  radiating 
pains,  etc. 

Reference  to  Hilton's  diagram  of  the  nerve  supply  and 
its  relation  to  other  spinal  nerves  shows  that  impressions 
from  the  fissure  are  carried  to  that  part  of  the  cord  which 
supplies  the  pudic  nerves  and  the  ilio-lumbar,  lambar  and 


70 


RECTAL   AND   ANAL   SURGERY. 


the  sciatics,  which  include  the  motor  supply  of  the  external 
sphincter  as  well  as  the  bladder  and  lower  extremities. 

In  this  peculiar  nervous  mechanism  we  find  an  explan- 
ation of  predisposing  causes  as  well  as  the  pathology  and  most 

important  symptoms  of  this 
remarkable  affection,  after  the 
ulcer  has  once  been  produced. 
As  to  the  immediate  causes  of 
the  fissure,  they  may  originate 
in  cracks  of  the  mucous  mem- 
brane, produced  by  forcing  out 
indurated  faecal  masses.  They 
occur  in  some  cases  from  de- 
generation of  the  raw  spots  left 
by  the  removal  of  piles,  and  in 
other  instances  from  ulceration 
caused  by  foreign  bodies  lodged 
in  the  sacculi  Horneri.  In 
short,  any  cause,  constitutional 
or  local,  capable  of  causing 
ulcers  in  other  parts,  may  affect 
the  verge  of  the  anus  in  the  same 
way.  The  perplexing  point  is 
not  the  origin  of  the  ulcers,  but 
their  astounding  painfulness. 
Three  causes  combine  to  pro- 
duce this  result: 

1.  The  verge  of  the  anus, 
like  the  orifices  of  all  other 
mucous  canals,  is,  even  in  its 
healthy  state,  extremely  sensi- 
tive to  painful  impressions. 

2.  The  sphincter,  excited  by  the  nerves  of  the  diseased 
parts  to  spasmodic  energy,  grasps  the  ulcer  very  forcibly  at 
every  contraction. 

3.  The  lower  extremity  of  the  fissure  receives  septic 


Fig.  31.  —  Diagram  of  Neeve 
Trunks  which  ake  conoekned 
IN  PEODuciNG  Reflex  Spasm. 

a.  Fissure,     c.  Sensory  nerve. 
d.  Motor  nerve,     e.  Pudic. 
f.  Ischiadic,     g.  Ilio-lumbar. 
hh.  Lumbar,     i.  Spinal  center. 


FISSUEE   OF   THE   ANUS.  71 

germs  fi"om  the  external  air,  which  propagate  putrescence  in 
the  secretions  of  the  sore  and  give  them  the  same  virulently 
irritating  quality,  which  putridity  generates  in  the  dis- 
charges of  ulcers  elsewhere.  The  facility  with  which 
antiseptics  often  cure  the  fissures  gives  support  to  this 
explanation. 

Symptoms. — No  disease  presents  a  more  distinct  clini- 
cal entit}'  than  fissure  of  the  anus.  From  its  symptoms 
alone,  without  any  physical  examination,  an  almost  certain 
diagnosis  could  be  derived  were  such  a  course  necessary. 
The  pain  associated  with  fissure  is  usually  felt  after  defeca- 
tion rather  than  during  the  act.  It  is  of  a  dull  yet  peculiar 
sickening  kind,  perhaps  similar  to  that  felt  after  injuries  to 
the  testicles,  and  is  described  as  intolerable,  most  patients 
being  completely  incapacitated  by  it  for  the  time  being. 
The  dread  of  this  suffering  causes  the  patient  to  postpone 
evacuating  the  bowels,  which  in  time  causes  hardened  accu- 
mulations and  aggravates  the  disease. 

Spasmodic  contraction  has  already  been  mentioned  as  a 
constant  element  in  this  disease.  The  iron  grip  of  the 
sphincter  has  not  a  little  to  do  with  the  intensity  of  the  pain 
in  all  probability.  Boyer  considered  this  contraction  the 
essential  feature  of  the  disease — a  view  which  very  few  sur- 
geons have  accepted.  It  is  probable  that  the  presence  of 
this  extreme  contraction  first  suggested  the  massage  cadence 
and  other  forms  of  dilatation  which  have  been  practiced  in 
this  affection.  Other  reflexes  su<^h  as  pains  in  the  loins  and 
lower  extremities,  retention  or  incontinence  of  urine  or  pros- 
tatic irritation  are  occasionally  present  as  in  most  rectal 
disorders.  Curschmann  asserts  that  spermatorrhoea  often 
co-exists  with  rectal  disease. 

The  local  signs  of  fissure  are  wholly  disproportionate  to 
the  general  mischief  they  produce.  If  the  patient  is  laid  on 
his  side  in  a  good  light,  with  the  knees  drawn  up,  the  sur- 
geon will  usually  see  a  red  prominence  close  to  the  verge  of 
the  anus,  looking  like  a  small  pile.     This  has  been  termed 


72  RECTAL   AND   ANAL   SURGERY. 

very   aptly  the  "  sentinel    pile."     If   lie    draw  the    mucous 

membrane  away  on  either  side,  he  will  unfold  a  raw  fissure 

or  groove,  running    upward,   which,  on    being    spread  out, 

presents  itself  as  a  small,  oval  ulcer  from  four  to  eight  lines 

,  ,,:,^^^,^-,..^  in  length.    A  Sims'  or  Allingham's  speculum 

assists  the  view.     Allingham  says  that  it  is 

not  uncommon  to  find  a  polypus  either  at 

the  upper  end  of  the  ulcer  or  lying  against 

it  on  the  opposite  wall  of  the  rectum. 

The  position   of   the  fissure   is    almost 

„  always  dorsal,  for  what  reason  is  not  known. 

FiG.32.— FissuKE  -^  ' 

OF  THE  Anus  When  unfolded  and  touched  with  a  probe 
NFOLDED.  ^^g  surface  is  found  to  be  excessively  tender, 

clearly  justifying  the  term  "  irritable "  which  is  often 
applied  to  it. 

Course  and  Prognosis. — It  cannot  be  said  that  a  fissure 
has  any  spontaneous  tendency  toward  recovery  if  let  alone. 
Years  may  elapse  without  any  other  change  than  the  gradual 
wearing  down  of  the  patient's  vitality  from  incessant  pain 
and  nervous  strain.  Van  Buren  mentions  cases  which  had 
existed  five  years  and  longer,  one  of  whom,  a  lady,  from 
sheer  dread  of  pain  would  postpone  the  natural  evacuations 
as  long  as  fourteen  days.  Complete  prostration  for  twenty- 
four  hours  followed  each  movement  and  large  quantities  of 
opiates  were  given  on  each  occasion.  AVith  proper  treatment 
fissures  of  the  anus  can  be  cured  with  almost  infallible" 
certainty  and  with  practically  no  risk,  the  operation  most 
practiced  being  one  of  the  simplest  known  in  surgery. 

Operative  Treatment. — A  fissure  can  be  cured  radically 
and  finally  by  making  an  incision  along  its  deepest  fold 
through  the  membranes  and  a  certain  distance — say  one- 
third  or  one-half  the  thickness  of  the  external  sphincter.  So 
simple  a  procedure  requires  no  further  description.  The 
line  of  incision  should  be  a  little  longer  than  the  fissure 
itself  so  as  to  make  sure  of  severing  all  the  exposed  nerve 
filaments.     An  anaesthetic  is  preferable,  yet  with  cocaine  it 


FISSURE   OF   THE  ANUS.  i6 

can  be  done  safely  and  without  extraordinary  pain.  This 
method  is  scientific  since  it  removes  at  once  the  principal 
source  o£  trouble  by  severing  the  exposed  nerve  i)i  sifu  and 
temporarily  at  least  abolishing  its  function. 

As  first  practiced  by  Boyer  the  division  of  the  sphincter 
was  made  complete  with  a  view  totally  to  prevent  its  spas- 
modic contraction  until  healing  had  occurred.  This  was 
eminently  successful  and  not  in  itself  a  severe  operation.  It 
was  found,  however,  by  Curling  and  the  English  surgeons 
that  simply  incising  the  mucous  membrane  and  a  little  of 
the  subjacent  tissue  practically  cured  as  well  as  the  complete 
division,  and  this  method  has  never  been  improved  by  later 
surgeons. 

Forced  Dilatation  of  the  anus  for  the  cure  of  fissure 
has  also  been  practiced  very  extensively  and  successfully 
since  it  was  first  employed  by  the  French  surgeons. 

Since  this  is  a  procedure  not  less  severe  than  the 
incision,  it  is  not  clear  that  it  has  any  great  advantage.  It 
rests  upon  a  sound  pathological  basis  and  is  altogether  a 
rational  method  of  accomplishing  the  same  result  sought  by 
dividing  the  sphincter.  Eecamier  practiced  what  was  in 
reality  a  dilatation  of  the  sphincter  under  the  name  massage 
cadencS  with  successful  results  in  the  cure  of  fissure. 

Maissonneuve,  going  much  further,  advocated  over- 
stretching the  anus  by  introducing  the  whole  hand  and 
then  forcibly  withdrawing  the  closed  fist.  It  is  doubtful  if 
stretching  is  any  less  severe  than  the  small  incision  of  the 
cutting  operation.  The  after-soreness  would  be  greater  in 
all  ordinary  cases.  On  account  of  the  prejudice  of  some 
patients  in  favor  of  non-cutting  operations  it  may  be  found 
to  be  preferable  in  a  certain  proportion  of  cases. 

A  considerable  proportion  of  cases  can  be  cured  by  still 
milder  measures.  It  is  necessary  first  to  expose  the  ulcer 
to  \iew,  and  to  blunt  its  sensibility  by  thoroughly  wetting 
its  surface  and  edges  with  an  eight  per  cent,  solution  of 
cocaine,  well  brushed  in  with  a  camel's  hair  pencil.     Allow- 


74  RECTAL   AND   ANAL   SURGERY. 

ing  alxiut  five  minutes  to  elapse,  tlie  brushing  should  be 
repeated  once  or  more  times,  so  as  to  get  a  decided  effect. 
The  sore  should  now  be  again  brushed  with  a  solution  of 
the  kind  given  in  this  formula: 

I^      Corrosive  sublimate gr.  j. 

Cryst.  carbolic  acid 3  ij- 

Hydrochlorate  of  morphia gr.  v. 

Water fl.  3iv. 

Mix.     S.    Apply  with  a  camel's  hair  pencil. 

Next,  dust  or  pack  the  fissure  with  dry  iodoform,  and 
place  the  patient,  if  possible,  in  bed.  This  dressing,  if 
repeated  once  a  day,  will  cure  great  numbers  of  cases. 
Carbolated  iodoform  ointment  may  be  pressed  into  the 
fissure  instead  of  iodoform,  if  preferred.  Antiseptics  of 
almost  any  kind,  carefully  placed  in  the  cavity  of  the  ulcer, 
will  cure  a  great  proportion  of  the  cases.  Kelsey  favors  a 
nightly  application  of  Goulard's  liniment,  and  also  has 
cured  many  cases  by  touching  the  surface  with  a  solution  of 
nitrate  of  silver  of  the  strength  of  five  or  ten  grains  to  the 
ounce  of  water. 

Allingham  strongly  advocates  applying  the  following 
ointment  several  times  a  day: 


Hyd.  sub.  chlor 

gr-  iv. 

Pulv.  opii 

gi'-  ij- 

Ext.  belladon 

gr-  ij- 

Ung.  sambuci 

!j- 

Misce. 

An  ointment  of  the  oxide  of  mercury,  thirty  grains  to 
the  ounce,  has  cured  many. 

The  following  plan  is  more  energetic,  and  very  com- 
monly succeeds.  First,  anaesthetize  the  ulcer  as  before  with 
applications  of  cocaine,  then  thoroughly  cauterize  the  whole 


FISSURE    OF   THE  ANUS.  75 

floor  of  it  with  a  stick  of  nitrate  of  silver,  and  fill  the  fissure 
with  this  ointment: 

I^      Iodoform 3j. 

Belladonna  ointment fss. 

Carbolic  acid gi"-  x- 

Simple  cosmoline 3ss. 

Mix. 
Apply  this  ointment   thoroughly  every  day,  after  having  each  time 
cleansed  the  sore  with  antiseptics,  and  repeat  the  nitrate  of  silver  very 
gently  every  third  day. 

Itinerant  Methods. — The  traveling  doctor  generally 
has  either  a  long  or  a  short  circuit.  The  long  circuit 
brings  him  back  to  the  same  place  in  four  weeks,  and  the 
short  one  in  two  weeks:  hence  he  regulates  his  times  of 
seeing  patients  by  the  time  of  his  return,  and  not  according 
to  the  patient's  needs,  leaving  some  placebo  to  occupy  the 
attention  between  times.  In  this  way  the  case  is  prolonged 
and  kept  on  hand  as  a  source  of  revenue,  according  to  one  of 
the  little  secret  books,  ''  from  six  to  eighteen  months,"  when 
it  should  be  finished  in  one-tenth  of  that  time. 

The  "  Brinkerhoff  System,"  as  applied  to  fissures  of  the 
anus,  is  this:  Once  or  twice  a  month,  as  the  itinerant  comes 
around  on  his  circuit,  he  inserts  his  little  speculum,  cleans 
out  the  ulcer,  and  applies  to  it  a  solution  of  nitrate  of  silver, 
forty  grains  to  the  ounce.  Between  the  applications,  the 
patient  uses  a  morning  and  evening  treatment  himself. 
Each  morning  he  is  to  evacuate  the  bowels,  then  inject  the 
rectum  with  lukewarm  water,  anc|  finally  insert  into  it  a  little 
ointment,  consisting  of  three  grains  of  carbolic  acid  and 
eight  grains  of  sulphur  to  the  ounce  of  vaseline  or  lard. 

For  evening  treatment  he  uses  "  Brinkerhoif's  Ulcer 
Remedy,"  having  the  following  composition: 

T^     Extract  of  hamamelis  (distilled) .  .  .  .  fl.  3v. 

Solution  of  persulphate  of  iron ''  3j. 

Ciyst.  carbolic  acid grs.  ij. 

Glycerine fl.  "ij.     n\. 

Add  half  a  teaspoonful  of  this  to  the  same  quantity  of  starch,  and 
about  an-ounce  and  a  half  of  water.    Inject  into  the  rectum  every  evening. 


76  RECTAL   AND   ANAL   SURGERY. 

This  "system"  is  gotten  up  for  itinerants  who  are 
expected  to  he.  ignorant,  and  who  cannot  be  trusted  with 
edge-tools;  it  therefore  sternly  prohibits  all  cutting  opera- 
tions, and  furnishes  no  instrument  with  which  an  incision 
can  be  made. 

Ulcers  Situated  Above  the  Anus. — When  ulcers  are 
situated  high  enough  to  be  entirely  above  the  anus,  and 
expose  no  part  of  their  length  to  the  reception  of  septic 
germs  from  the  atmosphere,  they  do  not  acquire  the  terrible 
irritability  of  true  fissure.  They  are  bathed  in  the  bland 
rectal  mucus,  which  itself  is  a  decided  antiseptic,  and  rarely 
become  the  seat  of  much  pain,  showing  in  that  respect  a 
wonderful  contrast  to  the  ulcers  situated  low  enough  to 
present  one  extremity  to  the  external  air. 

Causes. — The  causes  of  the  higher  ulcers  are  similar 
to  those  producing  ulceration  elsewhere,  such  as  foreign 
bodies,  mechanical  injuries,  simple  inflammation,  as  in 
dysentery,  tuberculosis,  syphilis,  chancroid,  sarcoma,  true 
cancer,  etc.,  etc.  In  the  prison  hospital  of  Saint  Lazarre,  in 
Paris,  deA^oted  to  the  treatment  of  diseased  prostitutes,  we 
were  shown  by  the  surgeon  in  charge  numerous  cases  of 
chancroids  of  the  anus  and  rectum,  caused  by  the  practice  of 
sodomy,  which  is  prevalent  to  a  great  extent  in  that  city. 
This  vice  is  so  rare  in  the  United  States,  except  among 
immigrants  from  Southern  Euroj^e  and  from  China,  that 
rectal  chancroids  hardly  exist  among  native  Americans.  We 
have  met  them  a  few  times,  however,  in  cases  of  recto- 
vaginal fistula,  where  the  virus  entered  the  rectum  through 
the  fistula.  The  ulcerations  of  tertiary  syj^hilis  are  liable 
to  attack  the  rectum  as  well  as  other  parts,  and  not  being 
dependent  on  contagion  for  their  rectal  location,  they  are 
not  very  uncommon  in  this  country. 

Clinical  History. — When  simple  ulcers  of  the  rectum 
are  of  very  recent  origin,  they  are  apt  to  be  accompanied 
with  pain,  tenesmus,  and  symptoms  of  dysentery,  with  dis- 
charges of  blood,  pus,  and  rectal  mucus,  as  well  as  faeces. 


FISSUBE    OF   THE  ANUS. 


t  i 


In  chronic  cases,  these  symptoms  are  mostly  absent,  though 
pus,  yellow  mucus  and  streaks  of  blood  are  found  in  small 
quantity.  The  proof  of  the  ulceration  is  mainly  obtained  by 
examination  with  the  finger  and  the  speculum.  If  the  ulcers 
are  phagedenic,  or  large  and  multiple,  they  may  occupy 
nearly  or  quite  the  entire  circumference  of  the  rectum,  and 
in  healing  induce  contraction  and  thus  produce  stricture. 
Most  strictures  originate  in  this  way. 


Fig.  33. 
Concave  Miekob  to  Reflect  Condensed  Light  into  the  Rectum.^  :!iTHE 

HEAD  BAND  MAY  BE  BEMOVED  AND  A  HANDLE  ATTACHED  AT  PLEASUBE. 

Diagnosis. — If  pus  is  discharged  from  the  anus,  and 
the  patient  shows  other  signs  of  tertiary  syphilis,  and  if  on 
examination  one  or  more  ulcers  are  found  without  other 
known  cause,  they  may  be  presumed  to  be  syphilitic.  If  the 
erosion  exists  on  the  surface  of  a  tender  and  painful  tumor, 
not  seeming  to  be  simply  inflammatory,  it  will  generally  be 


/»  RECTAL   AND   ANAL  SURGERY. 

found  cancerous.  The  microscope  will  complete  the  diag- 
nosis. If  a  tuberculosis  diathesis  is  present,  or  suspected, 
the  microscopic  search  for  the  tubercle  bacillus  will  assist 
the  diagnosis,  even  if  we  do  not  accept  the  bacillus  as  a 
cause. 

When  we  have  to  deal  with  simple  ulceration  well  above 
the  verge,  the  finger  often  helps  to  determine  their  size  and 
location,  but  it  is  not  sufficient  for  a  full  investigation.  In 
these  deep  cases  we  need  the  tubular  form  of  speculum,  and 
frequently  must  etherize  the  patient,  if  we  are  to  make  a 
thorough  search.  The  straight  tube  will  generally  reach 
far  enough,  but  the  curved  one  shown  on  page  16,  Fig.  8,  will 
enable  one  to  carry  the  search  still  higher.  For  a  thorough 
examination  it  is  necessary  to  empty  the  rectum  by  an 
enema. 

Treatment. — When  the  ulcers  are  due  to  any  constitu- 
tional disease,  they  will  usually  recover  by  simply  curing 
the  cause,  without  any  local  treatment;  but  if  there  is  any 
local  sepsis,  or  depraved  quality  of  the  intestinal  secretions, 
direct  applications  become  necessary.  In  either  case  a  pro- 
longed rest  in  bed  is  important.  The  great  value  of  the 
horizontal  position  in  hastening  the  cure  is  too  much  over- 
looked. "An  hour's  walking  and  standing  around  the  sick 
room  will  undo  more  than  the  other  twenty -three  can  gain." 
(Kelsey. ) 

The  local  medication  is  best  made  in  the  form  of  anti- 
septic washes  and  suppositories,  of  which  nitrate  of  silver, 
two  grains  to  the  ounce,  is  a  favorite.  A  large  injection  is 
thrown  in  and  allowed  to  run  out  again,  after  which  a  sup- 
pository, containing  three  grains  of  iodoform,  five  grains  of 
subnitrate  of  bismuth  and  a  tenth  of  a  grain  of  morphine, 
may  be  inserted.  The  suppository  may  be  used  twice  a  day, 
but  the  injection  only  once  in  two  days,  and  if  it  irritates  it 
should  be  made  weaker.  It  is  well,  however,  to  rinse  out 
the  rectum  daily  through  a  tube,  with  warm  and  slightly 
salted  water  containing  one  grain  to  the  ounce  of  carbolic 


FISSURE   OF  THE  ANUS.  79 

acid,  taking:  care  that  the  fluid  runs  well  out  ajjain,  lest  too 
much  carbolic  acid  be  absorbed.  When  the  ulcers  are  seen 
through  the  speculum  they  may  be  touched  with  nitric  acid, 
nitrate  of  silver,  comp.  tinct.  of  iodine,  or  carbolic  acid, 
but  the  speculum  should  not  be  inserted  with  irritating 
frequency. 

The  substance  of  the  whole  experience  of  surgeons  is 
that  simple  ulcers  ordinarily  heal  through  cleansing  and 
antisepsis.  It  is  very  diflPerent,  however,  if  the  ulcers  are 
chancroids,  or  the  result  of  tertiary  syphilis,  or  tuberculosis. 

Chancroids  in  the  rectum,  as  before  stated,  are  rare  in 
this  country.  If  discovered  they  will  present  the  yellow, 
diphtheritic  color  of  the  floor,  common  to  the  species  every- 
where, which,  with  the  history  of  the  case,  will  enable  one 
to  make  out  the  diagnosis.  It  is  necessary  to  treat  such 
cases  by  frequent  applications  through  the  speculum.  To 
this  end  the  rectum  should  first  be  emptied  and  antiseptically 
washed  out.  Then  inserting  the  speculum,  bring  chancroids 
well  into  view,  and  first  having  brushed  the  rectum  with  a 
four  per  cent,  solution  of  cocaine,  cauterize  them  with  a  stick 
or  glass  brush  dipped  in  fuming  nitric  acid.  Kinse  out  the 
surplus  of  acid,  remove  the  speculum  and  insert  a  supposi- 
tory containing  three  grains  of  iodoform,  five  grains  of  boric 
acid  and  a  fifth  of  a  grain  of  morphine.  This  should  be 
repeated  every  second  day,  until  the  yellow  color  of  the  floor 
of  the  ulcer  disappears,  and  a  rose  tint  takes  its  place,  indi- 
cating that  the  virus  of  chancroid  is  no  longer  present,  and 
the  ulcers  have  become  simple  bnes.  During  the  treatment 
the  rectum  should  be  washed  out  three  times  a  day  with  the 
same  washes  as  were  recommended  above  for  simple  ulcers, 
and  when  the  nitric  acid  applications  cease,  the  morphine 
may  be  omitted  from  the  suppositories,  unless  great  irrita- 
bility exists.  At  any  rate  it  must  not  be  given  a  great 
length  of  time  without  an  occasional  week  of  omission,  lest 
the  opium  habit  be  induced. 

If  tertiary  syphilis  exists,  the  case  requires  locally  mere 


80  RECTAL  AND   ANAL  SURGERY. 

washes,  like  those  directed  for  simple  ulcers,  but  constitu- 
tionally it  demands  a  vigorous  administration  of  iodide  of 
potassium  or  sodium  by  the  stomach. 

In  tuberculous  cases  the  local  sores  require  ordinarily 
only  washes  like  those  used  for  simple  ulcers,  though,  if 
tubercle  exists  in  the  ulcer  itself,  it  may  require  to  be 
scraped.  Such  cases,  however,  are  more  medical  than 
surgical,  and  require  the  same  general  treatment  as  is  given 
to  other  tuberculous  patients. 

When  the  ulcers  are  dependent  upon  the  depraved  con- 
dition of  the  system  caused  by  Bright' s  disease  of  the 
kidneys,  they  will  usually  be  incurable,  but  still  the  use  of 
mild  but  free  washings  will  alleviate  the  local  symptoms. 

Whenever  ulcers  occupy  a  large  portion  of  the  circum- 
ference of  the  rectum,  or  anus,  the  contraction  during  their 
healing  tends  always  to  induce  strictures,  which  can  only  be 
prevented  by  mechanical  dilatation,  a  subject  which  we  will 
consider  fully  in  the  section  on  strictures. 


CHAP  TEE    VIII. 
PROLAPSE    OF   THE    EECTUM. 

There  are  three  forms  of  rectal  prolapse: 

1.  Prolapse  of  the  mucous  membrane  alone,  as  repre- 
sented in  Fig.  34. 

2.  Prolapse  of  all  the  rectal  coats.  This  variety 
brings  doAvn  the  peritoneum  if  the  extrusion  proceeds  to 
some  distance,  as  is  shown  in  Fig.  35. 


Fig.  34. — Pbolapse  of  Mucous  Membbane  (Esniarch) 


3.  Prolapse  of  the  upper  part  of  the  rectum  into  the 
lower,  which  is  the  same  accident  which  is  called  invagina- 
tion or  intussusception  in  other  parts  of  tiie  canal. 

Prolapse  of  the  Mucous  Membrane. — This  is  the  most 
frequent  variety,  and  the  majority  of  cases  are  in  children 
under  five  years  of  age.  The  acute  cases  are  generally  in 
childi-en,  and  are  usually  produced  by  simple  excess  of 
straining  at  stool.     The  mucous  membrane  is  very  loosely 

6  81 


82 


RECTAL   AND   ANAL   SURGERY. 


attached  to  the  parts  beneath,  and  readily  protrudes.  Kelsey 
says  the  first  attack  always  comes  on  gradually,  hut  this  is 
probably  an  error,  as  it  often  occurs  as  a  sudden  accident 
in  young  children  who  have  shown  no  sign  of  it  before. 
Besides  straining,  we  have  for  causes  paralysis,  excessive 
dilatation,  and  ulcerative  destruction  of  the  sphincters,  or  of 
any  part  of  them. 

When  the  attack  comes  on  suddenly  there  is  consider- 
able pain,  and  a  red  and 
often  bloody  tumor  is 
found  projecting  from 
the  sphincter,  which  is 
sometimes  reduced  spon- 
taneously, and  at  others 
has  to  be  pressed  back 
by  the  hand.  It  is  natur- 
ally marked  by  circular 
folds  as  shown  in  Fig. 
34,  but  in  other  cases 
the  submucous  effusion 
renders  the  tumor 
smooth.  Prolapse  of 
the  mucous  membrane 
alone  rarely  projects 
more  than  two  inches. 
If  the  tumor  is  longer 
than  that,  especially  if 
it  assumes  a  cylindroid 
form,  other  coats  of  the  intestine  will  be  found  present  in 
the  mass. 

In  a  few  cases  we  have  the  third  form  of  this  accident, 
where  the  upper  part  of  the  rectum  projects  into  the  lower, 
and  even  considerable  lengths  of  intestine  from  above  have 
been  known  to  be  invaginated  and  protrude  through  the 
anus.  Mortification  of  the  protruded  part  occasionally 
occurs,  with  the  death  of  about  half  the  patients. 


Fig.  35. 
Pkolapse  of  all  the  Coats  (Esmarch). 


PROLAPSE    OF   THE   RECTUM.  83 

Treatment. — Whatever  the  form  of  the  accident,  etforts 
must  be  made  to  return  the  mass,  which  can  usually  be  done 
without  ether  by  first  washing  the  parts  with  solution  of 
cocaine,  and  then  pressing  them  back  with  oiled  hands. 
Persistence  in  taxis  will  almost  always  succeed.  In  many 
cases  the  patient  will  remain  cured,  if  he  refrains  from 
straining;  but  where  the  bowel  continually  comes  down, 
artificial  supports  must  be  used.  These  are  constructed  in 
two  ways.  In  one  a  belt  is  placed  around  the  waist,  and  an 
elastic  band  having  a  solid  or  inflated  pad  attached  is  passed 
between  the  thighs  in  such  a  way  as  to  press  the  pad  against 
the  anus.  The  anterior  part  of  the  band  is  divided  so  as  to 
come  up  to  the  belt  in  front  on  each  side  of  the  genitals. 
Another  form  consists  of  a  belt,  half  steel  and  half  leather, 
buckled  about  the  hips  just  above  the  trochanters,  while  a 
bent  steel  spring  passes  down  behind  and  carries  a  pad  to 
press  against  the  anus.  In  temporary  cases,  it  assists  the 
stability  of  the  pad  to  draw  the  nates  together  with  a  broad 
adhesive  plaster. 

The  bowel  being  returned,  and  provision  being  made 
for  the  time  being  for  retaining  it,  if  needed,  the  surgeon 
must  of  course  seek  to  correct  every  constitutional  or  local 
disease  tending  to  bring  on  the  prolapse,  and  it  is  not  neces- 
sary for  us  to  enter  extensively  into  that  branch  of  the 
subject.  Locally,  astringent  injections  are  of  value,  such  as 
solutions  of  tannin  and  alum,  sulphate  or  chloride  of  zinc,  or 
of  tincture  of  iron,  using  them  at  about  the  same  strength  as 
one  would  in  the  urethra;  that  is  to  say,  we  can  use  to  each 
ounce  of  water,  in  most  patients,  fifteen  grains  of  alum,  two 
of  tannin,  of  chloride  of  zinc,  or  of  sulphate  of  zinc,  varying 
according  to  the  tolerance  of  the  patients.  As  the  rectum 
absorbs  readily,  toxic  substances  cannot  be  used  except  in 
officinal  doses.  Astringent  suppositories  containing  alum, 
morphine,  extract  belladonna  and  cocaine  often  help.  Tannin 
is  incompatible  with  morphine  and  cocaine. 

Operative  Treatment. — When  the  prolapse  is  due  to  a 


84  RECTAL   AND   ANAL   SURGERY. 

rent  in  the  perineum,  or  across  the  sphincter,  or  to  a  gap 
made  by  ulceration,  it  can  be  remedied  by  cutting  away 
the  cicatrized  edges  of  the  gap  or  rent,  and  closing  them  by 
sutures. 

Where  the  case  is  a  chronic  protrusion  from  other 
causes,  and  ordinary  corrective  and  palliative  measures  have 
failed  of  adequate  effect,  then  energetic  operative  measures 
on  the  prolapsed  tissue  itself  are  justifiable.  The  direct 
amputation  of  the  protruded  mass  is  subject  to  two  objections. 
First,  the  cicatrix  left  after  the  amputation  is  a  ring  com- 
pletely surrounding  the  opening,  and  in  its  subsequent 
contraction  is  liable  to  result  in  stricture.  Secondly,  if  the 
prolapse  contains  any  fold  of  peritoneum,  the  opening  of 
that  sac  would  involve  some  danger,  though  the  precautions 
of  modern  surgery  can  reduce  the  peril  to  moderate  dimen- 
sions. It  is  also  to  be  remembered  that  the  prolapsed 
peritoneal  pouch  may  be  hernial,  to  the  extent  of  containing 
ovaries,  and  coils  of  intestines,  etc.  For  these  reasons 
amputations  are  not  to  be  resorted  to  except  when  special 
circumstances  compel  us  to  confront  the  danger.  If  the 
gravity  of  the  case,  however,  makes  the  amputation  neces- 
sary, it  should  be  done  with  all  the  antiseptic  precautions 
proper  to  intra-peritoneal  surgery.  The  mucous  membrane 
should  first  be  divided,  and  all  bleeding  vessels  tied.  The 
muscular  coat  should  next  be  treated  in  the  same  way.  An 
opening  should  then  be  made  in  the  peritoneum,  the  finger 
introduced,  and  the  presence  or  absence  of  any  hernial  pro- 
trusion ascertained.  If  any  viscera  are  down  they  are  to  be 
returned.  The  peritoneal  coat  is  then  to  be  divided,  and 
sewed  up  with  fine  antiseptic  animal  ligatures,  and  the 
mucous  and  muscular  coats  closed  over  it  in  a  similar 
manner,  Mikulicz  (Deutsch.  Geselsch.  ftir  Chirurg,  XVII, 
Kong,)  is  of  the  same  opinion,  and  would  also  apply  the 
plan  to  cases  of  chronic  prolapsed  invagination  of  the  colon. 
Two  feet  and  a  half  of  prolapsed  colon  were  removed  in  one 
instance.  Some  would,  however,  close  the  whole  by  anti- 
septic stitches  going  through  all  the  coats  at  once,  as  in 


PROLAPSE    OF   THE   RECTUM.  85 

ordinary  laparotomies.  This  is  better  than  Kleberg's  opera- 
tion of  tying  the  gut  in  two  halves  with  rubber  tubes. 
During  the  recovery  and  for  months  after  dilatation  must  be 
used  to  prevent  stricture. 

The  operations  most  in  favor  with  the  best  surgeons  are 
those  which  remove  or  destroy  a  part  of  the  mucous  mem- 
brane and  skin  near  the  verge  of  the  anus. 

Excision. — The  skin  of  the  vicinity  having  been  shaved 
and  disinfected,  the  patient  is  ansesthetized  and  placed  on 
his  back,  in  a  good  light,  with  the  knees  drawn  up  and 
asunder,  while  the  surgeon  sits  facing  the  perineum,  as  in 
lithotomy.  The  mucous  membrane  is  then  raised  from  the 
deeper  parts  by  suitable  toothed  forceps  or  a  tenaculum  on 
one  side,  and  removed  with  the  scissors,  leaving  a  broad 
denuded  oval  patch  or  wound,  longest  in  the  direction  of  the 
axis  of  the  rectum.  If  the  skin  participates  in  the  tumor,  a 
portion  of  that  also  is  included  in  the  lower  angle  of  the 
wound.  Another  similar  piece  is  taken  on  the  opposite  side. 
Some  surgeons  take  several  narrower  longitudinal  strips,  but 
always  leave  enough  mucous  membrane'  to  prevent  serious 
stricture.  Every  bleeding  vessel  should  be  tied,  and  the 
wounds  closed  by  sutures,  otherwise  dangerous  haemorrhage 
may  occur.  The  patient  should  be  then  confined  to  bed 
for  several  days,  with  gentle  compression  upon  the  tumor, 
unless  it  has  already  retracted  within  the  verge. 

Some  surgeons  advise  to  clip  out  sections  of  the  con- 
nective tissue  and  muscular  coat  with  the  mucous  membrane, 
but  if  there  is  reason  to  think  the  mass  contains  a  fold  of 
peritoneum,  this  must  be  done  with  such  caution  as  not  to 
open  that  sac. 

Cauterization. — Owing  to  the  dread  of  haemorrhage, 
and  the  fear  of  wounding  the  peritoneum,  many  of  the  best 
surgeons  prefer  the  actual  cautery.  The  patient  being 
anaesthetized  and  posed  on  the  table  as  before,  the  cautery 
instrument,  generally  a  narroAv  one,  is  applied,  beginning 
near  the  upper  part  of  the  protrusion,  and  di'awing  it  down- 
ward, going  deeper  and  wider  at  the  lower  part,  and  termi- 


Ob  RECTAL   AND   ANAL   SURGERY. 

nating  at  the  junction  of  the  skin  and  mucous  membrane. 
From  three  to  six  such  stripes  are  burned.  In  bad  cases, 
Allingham  burns  completely  through  the  sphincter  muscle 
itself  at  two  opposite  points,  having  previously  reduced  the 
protrusion.  The  contraction  following  the  burns  through 
the  sphincter  remedies  the  relaxed  condition  of  that  muscle, 
and  enables  it  to  hold  up  the  parts  above.  It  is  necessary, 
however,  that  the  patient  be  kept  in  bed  some  three  weeks, 
lest  the  cicatrices  stretch  out  and  leave  too  much  laxity  of 
the  parts. 

Potential  Cautery. — Owing  to  the  horror  felt  by  patients 
at  the  idea  of  being  burned  with  hot  irons,  many  surgeons 
have  used  the  potential  cautery,  employing  nitric  acid,  sul- 
phuric acid,  potassa,  potassa  cum  calce,  and  chromic  acid. 
These  plans  have  not  been  favorites,  owing  to  the  difficulty 
of  confining  the  caustics  to  the  desired  lines.  This,  how- 
ever, is  merely  from  want  of  due  preparation.  If  the  part 
to  be  destroyed  is  held  in  a  trough- shaped  clamp,  in  such  a 
way  as  to  conduct  off  the  caustic  fluids  formed,  and  if  the 
parts  adjacent  be  adequately  protected  with  folded  napkin- 
cloth  saturated  with  alkaline  carbonates,  in  case  acid  caustics 
are  used,  or  acid  solutions  if  alkaline  caustics  are  tried,  the 
result  to  the  patient  will  be  practically  the  same  as  if  the 
actual  cautery  had  been  employed,  though  the  surgeon  will 
have  had  a  little  more  trouble  with  his  preparations. 

The  Itinerant  Treatment. — The  itinerants  use  small 
hypodermic  injections  of  equal  parts  of  an  eight-grain 
solution  of  muriate  of  cocaine  and  phenol  sodique,  or  other 
weak  preparations  of  carbolic  acid.  They  insert  two  or  three 
drops  at  each  puncture,  and  scatter  the  punctures  about  an 
inch  apart  over  the  surface  of  the  tumor.  They  claim  to 
cure  in  from  one  to  three  visits  in  most  cases.  "  Brinker- 
hoff,"  however,  advises  his  itinerants  to  let  prolapsus  alone, 
and  says  he  can  give  them  no  method  of  treatment  worthy 
of  their  attention. 

Vidal,  of  France,  used  hypodermic  injections  of  ergo 
tine,  with  alleged  success. 


CHAPTER   IX. 

POLYPUS    AND     OTHER     NON-MALIGNANT 
GROWTHS. 

When  a  tumor  is  a  mere  hypertrophy  of  the  normal 
elements  of  a  mucous  membrane  and  of  the  sub-mucous  con- 
nective tissue,  it  is  usual  to  call  it  a  poly- 
pus. According  to  the  relative  amount  of 
mucous  glandular  tissue,  or  of  fibrous  sub- 
stance, the  poly})Us  is  hard  or  soft.  If 
the  papillae  of  the  surface  are  multiplied 
and  elongated  they  give  it  a  hairy  appear- 
ance. Others  are  knobby  and  wart-like  to 
the  look.  Some  are  smooth,  and  others 
are  granular  in  appearance  from  being- 
covered  with  the  follicles  of  Lieberkiilm, 
or  with  the  hypertroi)hied  closed  follicles.^       „    ^^'   l! 

•^  ^  ^  Club-ShapedPolypus, 

Some  are  pedunculated,  and  others  more      fbom    Patient    of 
sessile.     In  the  rectum  they  are  generally        uthoe. 
small,  but  have  sometimes  been  found  larger  than  an  orange. 
Polypi  are  generally  painless,  but  from  special  location  in 
the  grasp  of  the  sphincter,  or  other 
•  causes,   they   may  induce    suffering. 
If  they  are  of  some  size  they  C0,n  be 
generally  found  with  the  finger,  but 
sometimes  have  to  be  sought  through 
the  speculum. 

Treatment. — Polypi    are  to  be 
treated  by  removal.     The  only  mate- 

.  .  Fig.  37.     Rounded  Polypus. 

rial  danger  is  haemorrhage  rrom  the 

artery  of  the  pedicle,  though  one  death  is  on  record  from 

the  wounding  of  the  peritoneum.     This  was  in  the  practice 

87 


RECTAL   AND   ANAL   SURGERY 


of  the  celebrated  surgeon  Brock.  The  patient  died  of  peri- 
tonitis after  the  removal  of  a  polypus,  when  it  was  found  that 
it  had  originated  in  the  sigmoid  flexure,  and  had  lengthened 
its  pedicle  down  into  the  rectum,  bringing  with  it  a  small 
tube  of  peritoneum  in  the  center  of  the  pedicle.  The  best 
way  is  to  ligate  the  pedicle  close  to  the  mucous  membrane, 
and  snip  it  off  far  enough  outside  the  ligature  to  prevent 
the  knot  from  slipping.  Many  twist  them  oif,  and  "trust  to 
luck "  about  the  haemorrhage.  Where  there  is  nothing 
like  a  pedicle  to  be  tied,  resort  may  be  had  to  the  actual  or 

potential  cautery.  Whatever  method 
is  adopted,  the  cure  is  usually  per- 
manent. 

Itinerant  Treatment. — Brinker- 
hoff  directs  his  itinerants  to  tie  the 
pedicle  close  to  the  wall  of  the  gut 
Avith  waxed  saddler's  silk.  Then,  if 
the  pedicle  is  long,  they  are  to  snip  it 
off  outside  the  knot.  If  it  is  short 
they  leave  the  tumor  hi  situ,  put  tlie 
patient  to  bed,  and  constipate  the 
bowels  for  about  three  days,  when 
they  are  to  give  a  gentle  cathartic. 
Vegetation,  Warts  or  Papillomata. — These  growths 
are  hypertrophies  of  the  papillae  of  the  skin,  in  fact  a  kind 
of  external  villous  polypi,  so  to  say.  They  -were  formerly 
considered  syphilitic  growths,  but  at  present  this  idea  is 
abandoned,  though  they  generally  occur  on  patients  who 
have  practiced  venereal  excesses. 

In  females  they  are  to  be  found  on  both  the  anus  and 
vulva  at  once.  They  consist  of  numerous  little  pedicles 
whose  summits  branch  out  and  press  against  the  branches 
of  adjacent  pedicles,  so  that  the  whole  mass  sometimes  looks 
like  a  solid  tumor  on  the  surface,  yet  if  scissors  be  run 
under  so  as  to  snip  away  all  the  pedicles,  the  skin  is  found 
beneath  merely  dotted  pretty  thickly  with  the  small  stumps. 


Fig 


-Villous  Polypus. 


POLYPUS  AND    OTHER   NON-MALIGNANT   GROWTHS.         89 

Treatment. — Vegetations  may  be  sometimes  destroyed 
by  frequently  dusting  them  Avitli  tannin  and  burnt  alum, 
but  generally  the  best  way  is  to  anaesthetize  the  patient 
and  snip  them  aAvay  with  scissors,  using  astringent  lotions 
afterwards. 

Condylomata. — This  term  has  been  loosely  applied 
both  to  certain  elevated  mucous  patches  of  secondary 
syphilis,  and  to  mere  bunches  of  non-syphilitic  skin  about 
the  anus.  The  syphilitic  cases  will  disappear  on  using  reso- 
lute antisyphilitic  internal  medication.  The  non-syphilitic 
varieties  require  the  scissors  if  they  are  troublesome. 

Fibrous,  Fatty  and  Cartilaginous  Tumors  of  the 
Anus  and  Rectum. — These  are  rare.  If  they  become 
troublesome,  they  must  be  removed  by  excision. 

Cystic  Tumors. — These,  if  troublesome,  must  be  dis- 
sected out,  or  else  have  their  interiors  cauterized  with 
potassa  cum  calce.  Iodine  and  nitric  acid  are  not  sufficiently 
energetic  for  the  purpose. 


CHAPTER     X. 
MECHANICAL   OBSTRUCTION   OF   THE    RECTUM. 

Mechanical  obstruction  may  arise  from  stricture,  from 
foreign  bodies,  from  congenital  malformation,  from  the 
pressure  of  adjacent  tumors  or  displaced  organs,  from  spasm 
of  the  sphincter,  from  large  polypi  or  other  benign  growths 
in  the  rectum,  and  from  malignant  tumors. 

Stricture. — We  mean  by  this  term  a  non-congenital,  or 
acquired  narrowing  of  the  passage.  Probably  a  majority  of 
the  cases  are  due  to  phagedenic  ulcers,  some  venereal,  and 
others  not,  which  first  spread  around  the  inner  surface  of 
the  rectum  and  destroy  the  mucous  membrane  in  an  irregular 
band,  nearly  or  quite  around  the  circumference.  As  the 
ulcer  grows  older  and  heals,  or  attempts  to  do  so,  its  cica- 
tricial circle  or  cylinder  contracts  and  narrows  the  passage. 
It  is  said  that  tertiary  syphilitic  deposits  may  cause  stricture 
even  without  any  ulcer,  and  be  cured  by  iodide  of  potassium, 
so  that  the  iodide  thus  becomes  a  means  of  diagnosis.  xAt  first 
little  notice  is  taken  of  the  obstruction  by  the  patient,  but  at 
length  he  observes  an  increased  difliculty  in  expelling  solid 
fseces,  and  discovers  that  they  are  thin  or  slender,  as  if 
driven  through  a  small  orifice,  unless  the  obstruction  is  so 
high  up  that  the  faecal  mass  re-forms  itself  in  the  cavity 
between  the  stricture  and  the  anus.  In  some  cases  the  flat, 
tape-like  form  of  the  faecal  discharge  is  produced  only  when 
a  violent  straining  forces  the  stricture  down  through  the 
anus,  while  the  round  form  follows  all  milder  efforts,  the 
anus  then  resuming  its  function  and  moulding  the  mass.  If 
the  destruction  of  mucous  membrane  does  not  extend 
entirely  around  the  rectum,  the  symptoms  of  obstruction  at 

90 


MECHANICAL    OBSTRUCTION   OF   THE   RECTUM.  91 

length  cease  to  increase,  and  the  case  may  spontaneously 
improve  by  the  dilatation  of  the  uninjured  portion  of  mucous 
membrane  effected  by  the  daily  passage  of  f?eces.  If,  how- 
ever, the  ulcer  is  a  complete  C}dinder,  it  may  go  on  contract- 
ing until  the  stoppage  is  complete,  and  the  patient,  if  not 
relieved  promptly,  may  die  with  the  usual  symptoms  of 
mechanical  obstruction  of  the  boAvels.  When  the  obstruc- 
tion has  become  so  decided  that  the  patient  habitually  fails 
to  empty  the  bowels,  the  abdomen  is  usually  found  full  and 
tympanitic.  The  portion  of  intestine  just  above  the  stricture 
becomes  dilated,  and  frequently  its  muscular  coat  is  liyper- 
trophied  from  its  constant  straining,  but  at  other  times  is 
thin  from  expansion.  Ultimately  the  mucous  membrane 
is  prone  to  become  inflamed  and  ulcerated,  and  sometimes  is 
perforated,  producing  either  cellular  abscess,  or  fatal  peri- 
tonitis, according  to  the  site  of  the  perforation.  When 
there  is  no  perforation  there  is  often  a  low  grade  of  chronic 
peritonitis  with  adhesions,  pain  on  exertion,  vomiting,  etc. 
Even  if  no  perforation  or  peritonitis  ensues,  death  will 
follow  a  complete  mechanical  obstruction  in  a  short  time. 

Examination. — Preliminary  to  treatment,  the  surgeon 
must  mf.ke  a  careful  physical  examination.  Generally  the 
finger  will  suffice,  but  not  always.  The  rectum,  having  been 
emptied  by  enema,  and  the  patient  lying  either  on  the  side 
or  back,  the  index  finsfer  is  lubricated  and  inserted,  and  will 
generally  reach  the  stricture.  If  the  point  can  be  carried 
through,  one  can  determine  whether  the  strictured  portion  is 
short,  or  whether  it  continues  6n  for  some  distance.  If  the 
obstruction  is  beyond  the  reach  of  the  finger,  a  rectal  sound 
with  a  curved  staff,  with  about  six  interchangeable  bulbs  of 
different  sizes,  will  enable  the  surgeon  to  ascertain  the  size 
and  location  of  the  stricture.  (See  Fig.  5  on  page  14).  If 
it  be  very  small,  a  britannia  metal  urethral  sound  may  be 
required.  The  ordinary  straight,  stiff  rectal  bougies  are 
useless  here,  and  the  flexible  ones  of  AVales'  pattern  are 
little  better,  as  the  position  of  the  tips  cannot  be  known  on 


92  RECTAL   AND   ANAL   SURGERY. 

account  of  their  flexibility,  unless  a  steel  stafP  be  inserted 
tlirouijfli  them.  There  are  often  difficulties  in  distint^uishing 
a  stricture  from  an  obstructing  rectal  fold,  but  in  such  case 
great  advantage  is  obtained  by  distending  the  gut  with  air, 
or  with  warm  water,  which  smooths  the  folds  away,  and 
diminishes  the  perplexity.  Metallic  sounds  must  l)e  used 
with  the  greatest  gentleness,  lest  they  perforate  some  spot 
thinned  by  ulceration,  or  fragile  from  other  diseases.  They 
give  imperfect  information  because  they  may  be  stopped  by 
rectal  folds  where  no  stricture  exists,  yet  if  they  pass,  the 
fact  is  important  because  it  proves  that  there  is  at  least  no 
stricture  smaller  than  the  size  of  the  bulb  passed.  If  the 
stricture  is  only  a  little  beyond  the  finger,  it  is  well  to  anaes- 
thetize the  patient  and  insert  the  whole  hand  of  either  the 
surgeon  or  a  selected  assistant.  The  hand  should  be  narrow, 
well  lubricated,  and  the  fingers  and  thumb  gathered  into  a 
cone,  and  slowly  pushed  through  the  sphincter.  After  pass- 
ing the  sphincter,  the  force  used  must  be  very  moderate,  as 
the  destruction  of  the  elasticity  and  strength  of  the  walls  of 
the  gut  by  the  disease,  give  a  possibility  of  tearing  through 
into  the  peritoneal  cavity,  an  accident  which  has  occurred 
more  than  once. 

Treatment. — Constitutional  treatment  may  be  required 
to  remove  whatever  unfavorable  diathesis  be  present,  espe- 
cially the  syphilitic,  and  in  partial  stricture,  on  which  no 
operation  is  at  present  intended,  it  is  often  necessary  to  use 
laxatives,  to  keep  the  fseces  in  a  semi-fluid  condition,  as  well 
as  tonics  and  proper  regimen  to  sustain  the  patient.  Medical 
treatment  alone  will  rarely  cure  the  stricture  itself,  however, 
except  in  a  few  of  the  syphilitic  cases,  and  those  pseudo- 
strictures  which  consist  merely  in  spasmodic  action  of  the 
sphincters. 

The  operative  treatment  consists  in  dilatation,  divulsion, 
and  incision  both  internal  and  external,  to  which  may  be 
added  colotomy. 

Dilatation. — This  is  generally  commenced   by  gently 


MECHANICAL   OBSTRUCTION   OF   THE  RECTUM.  93 

inserting  one  or  more  lingers,  if  the  stricture  is  within  reach, 
and  repeating  the  process  at  intervals  of  two  to  six  days. 
The  parts  should  be  benumbed  with  cocaine  a  fe^v  minutes 
beforehand,  the  finger  well  lubricated,  and  slowly  inserted. 
When  the  orifice  becomes  too  large  to  be  further  distended 
by  the  finger,  some  conical  rectal  bougie  is  to  be  employed, 
of  which  Wales'  rubber  instruments  are  the  best  now  in 
market.  These  are  to  be  inserted  very  slowly,  increasing 
the  size  gradually,  so  as  neither  to  overcome  the  patient's 
fortitude,  nor  to  risk  bursting  through  into  the  peritoneal 
cavity.  Mechanically  speaking,  any  stricture  within  safe 
reach  can  be  gradually  dilated  to  any  desired  size,  exactly  as 
is  done  with  the  strictures  of  the  urethra,  but  the  greater 
size  of  the  rectum,  and  its  more  overpowering  nervous  sym- 


FiG.  39. — Sargent's  Rectal  Dilatok. 

pathies,  render  it  much  more  difficult  to  maintain  the 
fortitude  and  tolerance  of  the  patient  at  a  working  standard. 
Still,  by  gentleness,  encouragement  and  patience,  great 
results  can  often  be  obtained  by  the  gradual  method.  It  is 
claimed  that  a  rapid  dilatation  can  be  obtained  by  electricity 
passed  through  a  metallic  bougie  pressing  into  the  stricture, 
just  as  is  done  in  the  urethra,  but  we  have  not  personally 
tried  it.  * 

Wales  and  Davison  have  each  devised  dilators,  consist- 
ing of  elongated  rubber  sacs,  which  are  inserted  into  the 
stricture  in  the  empty  condition,  and  then  made  to  expand  by 
forcing  in  air  or  warm  water.  Very  good  results  can  be 
obtained  by  the  use  of  them. 

Divulsion. — When  the  stricture  is  well  below  the  peri- 
toneal folds, — that  is  to  say,  within  an  inch  of  the  verge, — it 
can  be  rent  open  by  force,  provided  the  vagina  in  the  female, 


94  RECTAL   AND   ANAL   SURGERY. 

or  the  uretlira  in  the  male,  are  not  involved  in  the  suV)stance 
of  the  induration. 

In  performing  this  operation  the  })atient  is  anaesthetized, 
and  the  usual  method  is  either  to  nick  the  inner  edge  of 
tlie  stricture  in  several  places  with  the  bistoury,  or  as  is  the 
better  way,  nick  in  one  place  only  and  that  directly  back- 
wards toward  the  sacrum,  so  as  to  guide  the  rupture  in  a 
direction  where  there  are  few  vessels,  and  no  peritoneum. 
The  divulsion  may  be  made  by  the  fingers,  by  conical  rectal 
bougies,  or  by  any  of  the  mechanical  divulsors  invented  for 
that  purpose,  of  which  there  are  several.  We  generally 
restrict  ourselves  to  the  fingers,  and  to  Wales'  rubber 
bougies,  preferring  them  to  the  weapons  of  steel.  The 
proper  cases  for  divulsion  are  those  where  the  patient's  forti- 
tude is  not  persistent  enough  for  gradual  dilatation,  or  when 
other  circumstances  compel  haste,  and  at  the  same  time  the 
stricture  is  quite  near  the  anus.  The  sole  advantage  of 
the  method  is  that  there  is  less  danger  of  haemorrhage  than 
in  cutting.  When  the  stricture  is  situated  much  more  than 
an  inch  above  the  verge,  the  danger  of  tearing  into  the  peri- 
toneum begins,  and  divalsion  is  then  correspondingly  dan- 
gerous. In  such  cases  it  is  to  be  avoided  unless  some  urgent 
reason  exists  for  braving  the  peril.  In  old  and  debilitated 
patients  there  is  some  danger  of  shock  after  divulsion,  and 
deaths  sometimes  occur. 

External  Incision,  or  External  Proctotomy. — In  some 
cases  where  both  dilatation  and  divulsion  are  unadvisable, 
we  must  either  put  the  patient  to  a  little  risk  of  a  smart 
haemorrhage,  or  else  relieve  him  by  the  rather  undesir- 
able operation  of  colotomy,  or  operate  by  cautery.  When 
proctotomy  is  done  with  the  cold  knife,  the  method  is  as 
follows:  The  rectum  being  emptied  and  the  anus  shaved, 
the  patient  is  anaesthetized  and  placed  either  in  the  lithotomy 
position,  or  on  his  right  side  with  the  knees  drawn  up.  The 
left  index  finger  is  oiled  and  inserted  up  to  the  stricture  with 
the  palmar  surface  toward  the  sacrum.     A  straight  probe- 


MECHANICAL    OBSTRUCTION    OF   THE    RECTUM.  95 

pointed  bistoury  is  then  made  to  glide  along  the  finger  and 
through  the  stricture,  if  the  latter  is  low  down,  or  only  to  it, 
i£  higher  up.  The  knife  is  then  swept  backward  along  the 
mesial  line  until  the  heel  comes  close  to  the  point  of  coccyx, 
while  the  point  rests  on  the  finger  in  the  rectum.  A  free 
gush  of  blood  follows,  but  the  wound  can  be  easily  spread 
wide  open  and  the  bleeding  vessels  secured.  Then,  if  the 
stricture  is  not  already  cut,  the  knife  is  passed  into  it  and 
cut  backward  into  the  wound  already  made.  The  wound  is 
then  tightly  packed  with  lint  and  the  patient  sent  to  bed, 
using  opiates  if  needed. 

The  dread  of  haemorrhage  has  caused  improvements  to 
be  devised.  The  incision  may  be  made  from  without  in- 
wards, by  the  galvano-cautery  knife,  and  most  of  the  danger 
of  lipemorrhage  avoided.  A  third  method  is  to  insert  a 
trocar  into  the  skin  below  the  tip  of  the  coccyx,  and  push  it 
straight  to  the  end  of  the  finger  inserted  as  before  said  into 
the  rectum.  Withdrawing  the  steel,  and  leaving  the  canula 
in  place,  a  platinum  wire  is  carried  into  the  rectum  and 
brought  out  of  the  anus.  The  canula  is  drawn  out,  the  ends 
of  the  wire  connected  with  the  battery,  and  the  loop  is  made 
sloAvly  to  burn  its  Avay  outward  by  gentle  traction  upon  it. 
A  fourth  plan  is  to  insert  the  trochar  as  before,  carry  the 
chain  of  an  ecraseur  through  the  canula  and  out  the  anus, 
and  attaching  the  chain  to  the  instrument,  crush  the  tissues 
through  in  the  usual  manner.  A  fifth  plan  is  to  grasp  the 
tissues  in  the  curved  jaws  of  the  ecraseur-forceps  of  our 
invention,  and  divide  them  In  that  way.  The  ecraseur 
methods,  however,  are  not  as  safe  from  risk  of  haemorrhage 
as  the  galvano-cautery. 

The  wound  is  dressed  antiseptically  and  left  open  during 
healing.  The  retention  of  faeces  is  not  always  perfect  after- 
wards, but  the  condition  even  then  is  preferable  to  that 
following  colotomy,  for  which  it  is  a  substitute. 

It  is  a  curious  fact  that  even  when  a  stricture  is  too 
high  up  to  be  actually  divided,  the  division  of  the  sphincters 


06  RECTAL   AND   ANAL   SURGERY. 

in  proctotomy  still,  in  some  way  not  well  iinderstood,  often 
greatly  relieves  the  obstruction. 

Internal  Incision,  or  Internal  Proctotomy. — This  is 
performed  hy  dividing  the  stricture  internally,  directly 
backwards  toward  the  sacrum,  and  sometimes,  also,  but  with 
care,  directly  forwards  a  moderate  distance.  By  thus  keep- 
ing in  the  mesial  plane  the  vessels  divided  are  small  and  the 
risk  of  haemorrhage  is  not  great,  yet  surgeons  dislike  to  per- 
form the  operation  because  the  sphincters  are  intact,  and 
hemorrhage,  if  it  occur,  will  be  concealed  from  view  until  it 
has  attained  dangerous  proportions,  and  at  the  same  time 
is  in  situation  where  measures  for  the  suppression  of  it  are 
very  difficult  of  application.  Still  peculiar  circumstances 
may  sometimes  compel  one  to  take  the  risk.  The  operation  is 
performed  as  follows: 

The  patient  being  j)laced  in  the  lithotomy  position,  or 
else  made  to  recline  on  the  right  side,  the  finger  is  passed 
in  and  the  point  of  it  cautiously  insinuated  through  the 
stricture,  with  the  palmar  surface  toward  the  sacrum.  A 
straight  probe-pointed  bistoury  or  a  lithotomy  knife  is  then 
made  to  glide  along  the  finger  through  the  constriction, 
and  then  to  cut  boldly  backward  toward  the  sacrum.  If  a 
narrow  ledge  or  shelf  exists  in  front,  an  incision  may  also 
be  made  in  the  mesial  plane  forward,  but  not  so  far  as  to 
endanger  the  peritoneum,  the  vagina,  nor  other  important 
organs. 

Lumbar  Colotomy. — If  the  condition  of  the  rectum  is 
such  that  no  operation  of  reasonable  safety  can  restore  the 
natural  route  of  the  faeces,  it  is  necessary  to  perform  left 
lumbar  colotomy,  which  is  done  in  accordance  with  the  usual 
directions  on  that  subject  in  all  surgical  text  books.  A 
description  of  the  operation  will  be  given  in  the  chapter  on 
Malignant  Tumors. 

Obstruction  from  Foreign  Bodies. — Foreign  bodies 
occasionally  obstruct  the  rectum.  Thus,  a  farmer  in  Michi- 
gan fell  upon  a  blunt  stake  of  half-decayed  wood,  which 


MECHANICAL    OBSTRUCTION    OF   THE   RECTUM.  1)7 

entered  the  amis  some  distance  and  broke  off,  leaving  the 
fragment  in  the  interior.  It  was  extracted,  and  the  patient 
recovered. 

A  laboring:  man,  accustomed  to  bolt  his  meals  with 
great  rapidity,  presented  himself,  with  obstruction  and  sharp, 
cutting  pains  of  the  rectum.  Nothing  was  visible  to  external 
inspection,  but  the  finger  being  introduced,  discovered  a 
large,  jagged  piece  of  mutton  bone  lying  crosswise  just 
above  the  verge. 

In  another  case,  a  crushing  fracture  of  the  pelvis  dis- 
lodged a  laro^e  flake  of  bone,  and  drove  it  into  the  rectum 
two  inches  above  the  anus. 

A  case  is  on  record  where  a  man  suffered  such  violent 
pain  from  the  presence  of  stone  in  the  bladder,  that,  in  his 
desperation,  he  seized  a  large,  jagged  stone,  five  inches  long, 
and  forcibly  thrust  it  into  his  rectum  completely  above  the 
sphincter. 

Various  slender  but  elongated  objects  which  have  been 
swallowed  by  the  patient,  such  as  nails,  needles,  fish  bones, 
chicken  bones,  splinters  of  wood,  etc.,  may  make  their  way 
without  difiiculty  downward  until  they  land  crosswise  above 
the  sphincter,  when  trouble  and  obstruction  for  the  first  time 
ensue.  In  such  cases  there  may  be  some  dexterity  required 
to  extract  the  foreign  bodies  with  the  least  irritation,  but  no 
formidable  difficulty  occurs.  The  foreign  object  can  usually 
be  turned  so  as  to  bring  it  down  easily;  but  if  not  it  may  be 
necessary  to  cut  it  in  pieces  Avith  bone  pliers,  or  even  to 
incise  the  border  of  the  anus  to  remove  it. 

Benign  Tumors  in  the  Rectum. — Polypi  and  other 
benign  growths  sometimes  become  so  large  as  to  obstruct  the 
canal.  In  these  cases  they  must  be  removed  by  the  measures 
already  described  under  the  head  of  "  Polypus,"  or  if  the 
situation  renders  that  impossible,  then  a  lumbar  colotomy 
may  be  required. 

The  malig^nant  tumors  will  be  discussed  under  a 
separate  head. 


98  RECTAL   AND   ANAL   SURGERY. 

Obstruction  by  Displaced  Organs. — Frequently  a  retro- 
flexed  or  retroverted  fundus  of  the  uterus  presses  upon  the 
rectum  sufficiently  to  make  a  partial  obstruction.  Similarly 
the  descent  of  enlarged  ovaries,  coils  of  intestines,  etc.,  into 
the  sac  of  a  hernia  alongside  the  rectum  may  cause  material 
embarrassment  in  its  functions.  The  only  cure  is  to  replace 
the  wandering  organs  where  they  belong. 

Pressure  of  Tumors  and  Swellings  Outside  the  Rec- 
tum.— Fibrous,  cartilaginous,  and  bony  tumors  of  the  pelvis 
sometimes  obstruct  the  rectum.  Cartilaginous  growths 
especially  may  fill  the  entire  cavity,  and  make  a  very  great 
obstruction.  In  some  cases  these  obstacles  can  be  removed 
by  carefully  planned  operations,  which  will  have  a  better 
hope  of  success  if  done  early.  Sometimes  the  form  and 
location  of  the  growth  admits  of  a  complete  operative  suc- 
cess in  relieving  the  rectum,  even  when  the  whole  tumor 
cannot  be  removed.  The  excision  of  some' projecting  edge 
or  angle  may  be  all  that  is  needed.  If,  however,  the 
obstruction  goes  on  increasing,  and  becomes  so  nearly  total 
as  to  threaten  the  destruction  of  the  patient's  health,  or  life, 
lumbar  colotomy  must  be  performed.  There  is  a  prevalent 
opinion  among  physicians  that  an  artificial  anus  is  a  terrible 
thing,  and  not  much  preferable  to  death.  This  is  an 
exaggerated  view.  True,  an  artificial  anus  is  a  source  of 
some  inconvenience,  yet  by  the  exercise  of  a  little  care  and 
ingenuity,  these  inconveniences  are  greatly  relieved,  and  the 
patient  may  make  his  life  very  comfortable  to  himself  and 
agreeable  to  his  friends. 

Inflammatory  swellings  may  so  press  upon  the  rectum 
as  to  impede  the  evacuations.  They  rarely  effect  a  complete 
obstruction.  If  they  should  do  so,  it  will  usually  be  found 
that  an  abscess  is  present  which  must  be  evacuated,  when 
the  obstruction  will  disappear.  A  solid  inflammatory 
swelling  must  be  managed  by  antiphlogistic  and  anti- 
suppurative  treatment  just  as  in  other  parts  of  the  body. 
We  never  knew  one  to  produce  complete  stopjjage,  but  if 


MECHANICAL   OBSTRUCTION   OF   THE  RECTUM.  99 

it  sliould  occur,  a  temporary  artificial  anus  might  become 
necessary. 

Spasmodic  Contraction  of  the  Sphincter. — This  is 
usually  caused  by  fissures  of  the  anus,  or  other  irritation  in 
the  vicinity.  It  does  not  amouut  to  complete  obstruction, 
yet  it  may  induce  constipation.  Usually  the  treatment  con- 
sists merely  in  the  cure  of  the  fissure,  or  other  local  cause, 
but  sometimes  a  forced  dilatation  is  also  useful. 

Impaction  of  Faeces. — The  cause  of  this  condition  is  a 
long  continued  omission  to  perform  the  act  of  defecation, 
whether  from  paralysis  of  the  expulsory  muscles,  spasm  or 
involuntary  contraction  of  the  sphincter  as  in  fissure  of  the 
anus,  or  in  any  other  condition  of  the  organ  rendering  defe- 
cation painful.  The  impaction  may  also  be  due  to  simple 
neglect  of  the  patient  or  of  his  nurses  to  secure  evacuations 
when  there  is  long  constipation,  or  to  a  torpid  dementia  of 
the  patient  causing  the  matter  to  be  overlooked  and  for- 
gotten. 

In  rare  instances  a  large  intestinal  concretion  has  been 
known  to  come  down  and  lodge  at  the  sphincter,  blocking  up 
everything  above  it. 

Whatever  the  cause  may  be,  the  hardened  fi«ces  gradu- 
ally fill  and  distend  the  rectum  with  a  somewhat  firm  and 
consistent  mass  which  at  last  the  patient  is  unable  to  expel. 
Similar  impactions  sometimes  occur  higher  up  in  the  colon 
and  even  as  high  as  the  caecum  itself. 

The  diagnosis  is  not  difficult  if  the  finger  is  introduced 
into  the  rectum,  but  if  that  test  be  omitted  all  sorts  of  errors 
may  be  possible.  A  traveling  foreigner  once  called  on  the 
writer  to  see  his  wife,  who  was,  he  said,  in  labor.  The 
absence  of  any  sign  of  a  gravid  uterus  led  to  an  examination 
of  the  rectum,  which  was  enormously  distended  with  hard- 
ened fseces.  The  griping  pains  provoked  by  the  expulsory 
efforts  led  the  woman  to  suppose  she  was  about  to  have  a 
miscarriage.  Sometimes  the  irritation  of  the  mass  provokes 
a  frequent  catarrhal  discharge  with  pain,  etc.,  but  no  full 


100  RECTAL   AND   ANAL   SURGERY. 

evacuation.  Such  cases  have  even  been  called  diarrhoea, 
and  the  condition  aggravated  by  the  use  of  remedies  which 
stop  evacuations. 

The  reflex  irritation  sometimes  provokes  a  dry  cough, 
in  accordance  with  the  general  law  that  irritations  of  the 
anus  have  a  reflex  irritating  influence  on  the  larynx,  a  fact 
known  to  some  professional  singers,  who  carefully  observe 
their  own  condition.  The  fsecal  mass,  examined  from  the 
vaginal  side,  has  often  been  supposed  to  be  a  tumor. 

If  the  obstruction  goes  to  an  extreme  degree  it  may 
bring  on  vomiting  as  in  mechanical  obstructions  of  the 
bowels  generally. 

The  treatment  is  not  usually  difiicult.  In  mild  cases  a 
cathartic,  or  even  a  large  injection  will  often  suffice.  In 
others  the  fingers,  either  alone,  or  aided  by  such  a  scoop  as 
is  found  in  lithotomy  cases,  or  a  large  curette  will  accomplish 
such  a  reduction  of  the  mass  as  will  allow  the  work  to  be 
finished  by  cathartics  and  enemas.  In  married  women  two 
fingers  in  the  vagina  assist  very  much  in  forcing  down  the 
masses.  In  bad  cases  it  is  necessary  to  anaesthetize  the 
patient,  dilate  the  anus,  and  then  with  the  fingers  and  a 
scoop,  or  a  strong  desert-spoon  patiently  dislodge  the  mate- 
rial. As  there  is  often  a  large  reserve  of  material  in  the 
colon  above,  cathartics  are  needed  until  the  whole  is 
emptied. 


CHAPTER     XI. 

MALIGNANT    TUMOES    OF    THE    ANUS    AND 
EECTUM. 

These,  as  in  other  parts  of  the  body,  may  be  carcinomas 
or  sarcomas.  The  carcinomas  are  the  most  numerous  of  the 
two  in  this  locality,  but  whatever  their  relative  frequency, 
many  authors,  including  Cripps  and  Kelsey,  include  both 
under  the  general  term  cancer,  while  others  apply  that  name 
only  to  the  carcinomas.  The  sarcomas  are  rare  in  this  loca- 
tion, but  deport  themselves  when  found  much  as  they  do 
elsewhere. 

Causes. — The  etiology  of  both  forms  of  malignant 
disease  is  unknown.  Much  has  been  said  about  a  hereditary 
tendency  to  cancer.  We  published  some  years  ago  statistics 
of  inquiries  into  the  ancestry  of  one  hundred  cancer  patients, 
showing  that  they  had  almost  exactly  the  same  amount  of 
that  disease  among  their  parents  and  grandparents  as  prevails 
on  the  average  among  the  adults  of  the  whole  community. 
About  the  same  time,  Mr.  Harrison  Cripps,  of  London, 
showed  that  the  parents  of  cancer  patients  in  St.  Bartholo- 
mew's Hospital  had  the  same  average  amount  of  cancer 
among  them  as  is  found  among  the  adults  of  the  whole 
English  people,  according  to  the  statistics  of  the  Registrar 
General.  These  careful  analyses  of  masses  of  facts,  joined 
to  others  of  the  same  character,  tend  to  weaken  the  whole 
theory  of  hereditary  transmission  of  cancer,  whether  in  the 
rectum,  or  elsewhere.  Turning  to  other  causes,  we  find  that 
the  statistics  of  the  United  States  Census  Bureau  show  a 
clear  relation  between  cancer  and  climate,  as  we  have  else- 

101 


102  RECTAL   AND   ANAL  SURGERY. 

where  proven  by  collating  the  figures  of  three  successive 
decennial  censuses  of  the  United  States.  It  is  clear,  that  in 
this  country  cancer  [)revails  most  near  the  sea,  and  least  at  a 
distance  from  it;  also,  that  at  equal  distances  from  the  sea, 
it  abounds  decidedly  more  at  the  north  than  at  the  south. 
What  this  peculiar  influence  is,  which  is  found  prevailing  at 
the  north,  and  near  the  sea,  is  utterly  unknown.  The  clinical 
phenomena  constantly  suggest  that  it  is  a  microbe  introduced 
into  the  body  from  without,  but  the  efforts  of  microscopists 
to  identify  it,  though  claiming  success,  still  require  fuller 
confirmation.  At  present  we  must  be  content  with  a  degree 
of  uncertainty.  The  advocates  of  the  microbe  theory  point 
out,  in  support  of  that  opinion,  the  undeniable  fact  that 
cancer  of  the  rectum  is  most  frequent  near  the  outlet,  and 
diminishes  as  we  go  upward,  as  if  it  had  its  origin  in  some 
germ  entering  the  parts  from  external  sources, — a  fact  of 
considerable  weight,  though  not  decisive  of  the  question. 
Mr.  Cripps  has  given  in  his  valuable  work  a  very  careful 
discussion  of  the  etiology  of  rectal  cancer,  and  supports  the 
same  view.      ("  Cripps  on  the  Rectum,"  p.  315.) 

Carcinoma  of  the  rectum  often  spreads  in  a  flat  stratum 
between  the  mucous  membrane  and  the  sphincter,  where  it 
feels  somewhat  as  if  a  foreign  body  had  gotten  itself  bedded 
in  the  tissues,  but  in  other  cases  it  is  a  more  rounded  or 
irregular  mass.  In  either  case,  it  gradually  extends,  infects 
the  mesenteric  glands  and  the  liver,  and,  in  short,  destroys 
the  life,  like  any  other  carcinoma.  Occasionally  we  see  the 
colloid  forms,  as  in  the  upper  viscera. 

In  the  majority  of  cases  ulceration  of  the  surface 
takes  place,  bat  not  rapidly  enough  to  prevent  the  increase 
of  the  size  of  the  mass,  so  that  in  many  instances  complete 
obstruction  of  the  rectum  occurs.  The  pathology  of  the  dis- 
ease is  very  interesting,  but  our  limits  do  not  permit  entering 
upon  it.  We  can  only  refer  the  reader  to  an  admirable 
discussion  of  the  subject  in  "  Cripps  on  the  Diseases  of  the 
Eectum,"  pp.  288  to  370. 


MALIGNANT   TUMORS   OF  THE   ANUS   AND   RECTUM.      103 

Diagnosis. — Except  in  very  early  stages  it  is  not  usu- 
ally difficult  to  distinguisli  rectal  cancer  from  other  growths. 
If,  however,  there  is  ground  of  doubt,  the  location  is  such 
that  it  is  easy  to  excise  a  sample,  and  subject  it  to  micro- 
scopic examination.  The  fungous  form  of  cancer  might  be 
taken  for  an  innocent  villous  growth  by  one  unaccustomed  to 
distinguish  them.  However,  the  following  characters  will 
guide  one  generally  to  a  correct  conclusion:  Villous  inno- 
cent growths  are  usually  pedunculated;  cancers  rarely  so. 
Villous  tumors,  unless  ulcerated,  are  bathed  in  healthy, 
transparent  mucus :  cancers  discharge  offensive,  dirty-looking 
matter,  which  is  neither  mucus  nor  healthy  pus.  Villous 
tumors  are  soft,  but  yet  somewhat  tough;  while  the  fungous 
cancer,  though  somewhat  soft,  is  less  so,  and  yet  breaks 
readily  under  the  finger  nail,  and  easily  bleeds.  The  villous 
tumor  springs  from  a  soft,  healthy  mucous  membrane,  which 
glides  fi'eely  on  the  deeper  coats;  while  the  cancerous  fun- 
gous grows  from  an  indurated  lump,  or  patch,  in  the  bowel, 
which  seems  fixed  or  rigid. 

In  suspected  rectal  tumors,  where  the  diagnosis  is 
doubtful,  a  small  specimen  should  be  taken  for  microscopic 
examination,  and  if  the  case  is  truly  malignant,  the  typical 
structure  of  carcinoma,  or  of  sarcoma,  will  usually  be  found 
by  a  competent  microscopist.  The  situation  renders  it  easy 
to  excise  a  sample.  If  the  village  practitioner  be  not  skilled 
in  microscopic  pathology,  he  can  place  the  sample  in  a  vial 
of  alcohol,  and  send  it  to  a  competent  pathologist  in  some 
larger  town. 

Treatment. — This  may  aim  at  a  radical  cure,  or  at 
simple  palliation.  The  radical  cure  consists  in  the  complete 
extirpation  of  the  tumor,  and  of  a  stratum  of  apparently 
sound  tissue  around  it.  Numerous  variations  have  been 
devised  in  the  details,  but  the  following  description  will  give 
the  plans  mainly  adopted  by  the  best  surgeons,  among 
whom  Volkmann  has  perhaps  given  the  most  systematic 
account : 


104  RECTAL   AND   ANAL  SURGERY. 

1.  When  the  tumor  occupies  a  circumscribed  spot  only 
on  the  circumference  of  the  lower  rectum,  or  of  the  anus,  we 
first  make  a  thorough  dilatation  of  the  anus,  and  then  boldly 
excise  the  tumor,  cutting  far  enough  from  it  to  take  away 
all  the  diseased  tissue.  If  the  tumor  is  somwhat  high  up, 
we  pull  it  down  with  vulsellum  forceps,  and  if  the  dilatation 
of  the  anus  does  not  sufficiently  expose  it,  we  take  a  bistoury 
or  scalpel  and  divide  the  posterior  margin  straight  back  to 
the  coccyx.  After  the  removal  of  the  growth  we  study  the 
form  and  dimensions  of  the  wound,  and  so  far  as  its  extent 
will  permit,  close  it  with  sutures,  and  guard  it  from  serous 
infiltration  by  drainage  tubes. 

2.  In  some  cases  the  tumor  involves  the  entire  circum- 
ference of  the  rectum,  but  has  not  infected  the  anus.  We 
then  divide  the  sphincter  backward  to  the  coccyx,  and  also 
forward  into  the  perineal  region.  The  posterior  incision 
goes  deepest.  Drawing  the  two  halves  of  the  anus  asunder, 
the  growth  is  taken  out,  and  the  gap  is  filled  l)y  drawing 
down  the  mucous  membrane  and  stitching  it  to  the  cut 
margin  below.  The  two  halves  of  the  sphincter  are  next 
closed  with  deep  sutures,  and  a  drainage  tube  inserted  into 
the  posterior  seam. 

3.  In  other  cases  the  growth  not  only  occupies  most 
or  all  of  the  circumference  of  the  rectum,  but  the  anus  also. 
We  then  proceed  as  follows:  Dividing  the  anus  behind  and 
before,  as  already  mentioned,  we  commence  outside  the  line 
of  disease,  and  dissect  upward  outside  the  gut  until  we  get 
above  the  cancer.  If  a  hole  should  be  cut  into  the  peritoneum, 
it  is  plugged  with  a  well  carbolized  sponge.  The  rectum  is 
next  cut  off,  the  tumor  removed,  and  all  bleeding  vessels 
secured.  Next,  the  opening  in  the  peritoneum  is  sewed  up, 
and  if  the  bowel  will  yield  to  tension,  it  is  drawn  down  and 
stitched  to  parts  below.    However,  this  cannot  always  be  done. 

The  operation  is  a  bloody  one  in  spite  of  all  care,  and 
every  preparation  must  be  made  for  promptly  arresting 
haemorrhage. 


MALIGXAXT    TV  MORS    OF   THE   AXUS   A\D    RECTUM.      105 


The  French  surgeons  have  used  the  ecraseur  instead  of 
the  knife  to  divide  the  tissues,  thus  diminishing  the  risk 
of  haemorrhage,  but  probably  increasing  the  shock.  Cripps 
devised  an  ingenious  method  of  making  a  strong  whip-cord 
do  service  in  dividing  the  tissues,  instead  of  the  chain  of  the 
ecraseur.  The  platinum  wire  of  tlie  galvauo-cautery  and 
the  galvano-cautery  knife  are  used  with  excellent  effect  to 
avoid  hfemorrhage.  Verneuil,  of  Paris,  uses  both  the  ecraseur 
and  the  galvano-cautery  knife  in  the  same  operation.  The 
ecraseur-forceps  of  our  own  devising  is  more  convenient  of 
application  than  the  chain  ecraseur.  It  is  sometimes  neces- 
sary to  excise  the  coccyx  and  a  little  of  the  sacrum  to  enable 
one  to  reach  the  rectum  at  a  sufficiently  high  point. 

The  mortality  of  the  high  operations  is  pretty  heavy, 
but  that  of  the  low  ones  less  so.  The  peritoneum,  though 
variable,  comes  down  on  the  average  pretty  near  to  the 
highest  point  which  can  be  reached  by  the  index  finger ;  and 
this  point  is  called  by  Kelsey  the  "  danger  line." 

Taking  all  cases  together,  we  have  the  following  table: 


Authority. 

Total  Cases. 

Died  of  Opera- 
tion. 

Diseases  Known 
to  have 
Ketiirned. 

Disease  not 
returned  at 
times  from  a 
few  months    to 
three  years. 

Cripp's  Collection . . 

Allingham 

Billroth 

64 
13 

Not   stated. 

11 

0 

13 

20 
13 

Not  stated. 

34 
0 
0 

These  statistics  are  impei'fect,  and  therefore  unsatis- 
factory, but  they  show  at  any  rate  that  some  cases  are 
permanently  cured. 

DiefPenbach  claimed  thirty  cases  permanently  cured, 
but  in  his  day  the  means  of  accurate  diagnosis  of  carcinoma 
did  not  exist,  and  the  correctness  of  his  statistics  is  more 
than  doubted. 

Sarcoma  of  the  Anus  and  Rectum. — The  diagnosis 
from  carcinoma  must  be  made,  if  at  all,  by  the  microscope. 


106 


RECTAL   AND   ANAL   SURGERY. 


Its  early  removal  is  as  urgent  as  that  of  carcinoma,  and  its 

prospect  of  success  is  much  better. 

Palliative 
Operations. — 
Malignant  tu- 
mors are  prone 
to  block  up  the 
anus  and  pro- 
duce first  a  stric- 
ture, and  grad- 
ually a  total 
obstruc  tion  ; 
hence,  in  cases 
too  far  gone  to 
admit  of  exci- 
sion, we  must 
combat  the  oc- 
clusion. As  the 
stricture  comes 
on  gradually,  it 
can  usually  be 
overcome  by  in- 
serting  from 
time  to  time  a 
conical  rectal 
bougie,  giving 
an  anaesthetic  if 
necessary.  This 
ruptures  the  ob- 
structing belt, 
and  gives  re- 
newed ease  each 
Fig.  39.  time.     In  some 

Canceeous  Stbictube  of  the  Rectum  (Esmarch).      cases  it  is  iusti- 

fiable  to  scoop  away  some  of  the  mass  with  the  curette.     If 
the  obstruction  has  become  nearly  complete  and  extends  so 


MALIGNANT   TUMORS   OF   THE   ANUS  AND   RECTUM.      107 

high  that  it  cannot  be  locally  mastered,  we  must  resort  to  left 
lumbar  colotomy,  which  relieves  the  distress  and  obviates 
the  immediate  danger.  In  short,  it  enables  the  patient  to 
evacuate  the  bowels  in  comfort  as  longf  as  the  disease  in 
other  parts  permits  him  to  live.  As  the  disease  progresses, 
anodynes  may  be  used  according  to  the  necessity. 

Colotomy  for  Cancerous  Occlusion  of  the  Rectum.^ 
Some  writers  have  tried  to  introduce  the  polyglot  word 
"Colostomy,"  so  as  to  get  in  the  Latin  word  os,  a  mouth, 
between  the  two  Greek  elements  coJo  and  fonij,  intending 
apparently  to  express  the  idea  of  cutting  the  colon  to  make 
a  mouth.  Aside  from  the  allDsurditv  of  callino:  an  anus  a 
mouth,  it  is  bad  literary  usage  to  mix  two  languages  in 
coining  a  new  compound  term.  The  only  way  to  make  a 
correct  Greek  derivative  for  this  absurd  purpose  would  be 
to  say  "  Colostomatomy,"  but  this  would  be  an  intolerably 
long  and  harsh  word.  There  is  little  need  of  lugging  in  a 
Greek  or  Latin  root  to  express  the  motive  of  the  operator  in 
making  the  incision.  "Colotomy'"  sufficiently  indicates  the 
operation  itself. 

In  all  ordinary  cases,  the  opening  in  the  left  lumbar 
region  behind  the  peritoneum,  is  to  be  preferred.  This  is 
sometimes  called  left  lumbar  colotomy,  or  Calliseu's  opera- 
tion. Its  merit  is  that  it  does  not  open  the  peritoneal  cavity, 
and  this  is  very  important,  for  in  spite  of  occasional  assertions 
to  the  contrary,  careful  surgeons  know  very  well  that  anti- 
septic precautions  have  only  lessened,  but  not  abolished,  the 
dangers  of  laparotomy. 

The  method  of  procedure  is  as  follows:  The  skin  of 
the  left  lumbar  region  should  be  scrubbed  with  soap  and  an 
antiseptic  solution  several  times  during  the  thirty-six  hours 
preceding  the  operation,  and  during  the  last  six  hours  should 
be  kept  moistened  with  the  same.  The  patient  is  anaes- 
thetized and  laid  on  a  table  in  a  good  light.  At  this  point 
some  writers  have  recommended  to  distend  the  bowel  by 
injecting  air  into  the  anus,  so  as  to  make  the  colon  larger 


108  .  RECTAL   AND   ANAL   SURGERY. 

and  easier  to  find.  The  grimness  of  this  joke  will  be  obvious 
if  we  consider  that  the  anus  in  these  cases  may  be  closed  by 
the  cancer  so  effectually  that  neither  air,  nor  anything  else, 
can  be  gotten  through.  However,  there  is  little  need  of 
clysters.  The  bowels  are  usually  well  distended  already 
with  their  retained  contents. 

The  patient  being  laid  with  the  right  side  down  and  a 
cushion  under  the  loin,  the  surgeon  proceeds  to  ascertain 
the  position  of  the  descending  colon.  The  area,  or  field  of 
operation,  is  bounded  above  by  the  last  rib,  below  by  the 
crest  of  the  ilium,  behind  by  the  longissimus  dorsi,  and 
the  common  mass  of  the  ereciores  spincB  muscles,  and  in 
front  by  a  perpendicular  line  carried  upward  from  the  center 
of  the  crest  of  the  ilium.  In  this  quadrangle  lies  the 
descending  colon  with  its  axis  about  half  an  inch  posterior 
to  the  vertical  line  drawn  upward  from  the  center  of  the 
crest  of  the  ilium.  The  center  of  the  crest  is  best  found  by 
running  a  line  from  the  anterior  to  the  posterior  spinous 
process,  and  erecting  a  vertical  one  from  its  center.  Mark 
the  position  of  the  axis  of  the  intestine,  as  above  ascertained. 
Now  make  an  incision  through  the  skin  about  four  and  a 
half  inches  long,  whose  center  shall  cross  the  line  marking 
the  axis  of  the  gut.  The  incision  should  be  oblique,  passing 
downward  and  forward  in  the  same  direction  that  a  rib 
might  be  supposed  to  assume  if  one  existed  at  that  level,  and 
should  be  about  half  way  between  the  last  rib  and  the  crest 
of  the  ilium.  This  direction,  however,  is  not  imperative.  If 
special  circumstances  require,  it  can  be  perpendicular  or 
transverse.  Dissecting  carefully  down,  the  latisimus  dorsi, 
the  thick  border  of  common  mass  of  spinal  muscles  and  the 
anterior  edge  of  the  quadratus  lumborum  will  come  to  view, 
and  external  to  them  the  external  oblique  muscles  and  its 
fascial  origin.  Divide  the  fascise  and  the  external  oblique 
muscle  on  a  grooved  director,  and  also  the  anterior  or  external 
border  of  the  quadratus  lumborum.  That  portion  of  the 
gut  not  covered   by  peritoneum,  lies  under  the  border  of 


MALIGNAXT    TUMORS    OF   THE   ANUS   AND   RECTUM.      lOV) 

the  quadratus.  The  loose  fat  connected  with  the  colon  and 
kidney  is  now  exposed,  unless  it  has  been  removed  by 
emaciation.  Displace  the  fat  by  the  finger  and  the  gut  will 
come  to  view,  and  may  be  recognized  by  its  large  size,  its 
greenish  color,  the  presence  of  one  of  the  longitudinal 
muscular  bands  and  its  tendency  to  sacculation  of  the  walls. 
Now  at  a  point  three-quarters  of  an  inch  in  front  of  the 
perpendicular  axial  line  of  the  gut,  pass  a  semicircular 
needle  through  the  skin  of  one  edge  of  the  wound  down  into 
the  gut  and  thence  out  again  about  half  an  inch  from  the 
point  of  entrance,  and  out  through  the  skin  of  the  other  edge 
of  the  wound,  and  draw  after  it  a  stout  ligature.  Repeat 
this  process  behind  tJie  axial  line,  and  by  these  loops  raise 
the  gut  up  into  the  wound.  Next,  incise  the  gut  parallel  to 
the  incision  in  the  skin  nearly  fi-om  one  loop  to  the  other, 
A  blunt  hook  will  now  easily  draw  out  the  loops  fi"om  the 
inside  of  the  gut,  and  by  diyiding  them,  four  ligatures  are  at 
once  produced,  wherewith  to  tie  the  cut  edges  of  the  intestine 
to  the  skin.  A  few  more  stitches  are  required  to  support 
adjacent  parts. 

After  the  siu'plus  contents  of  the  intestine  have  escaped, 
the  wound  can  be  dressed  with  oakum,  or  any  other  porous 
antiseptic  absorbent.  The  stitches  should  remain  until,  by 
their  looseness,  they  show  that  they  are  no  longer  useful. 


CHAPTER    XII. 

MALFORMATIONS     OF     THE     RECTUM- 
PRURITUS    ANI. 


Children  are  occasionally  born  with  no  outlet  to  the 
bowel.     In  some  instances  the  obstruction  is  merely  a  thin 

1 


Fig.  40. — Impekfoeate  Anus  (Esmarch). 

membrane  across  the  anus,  through  which  the  dark  shade  of 
the  meconium  shows.    In  other  instances  the  anus  and  lower 

110 


MALFORMATIONS   OF   THE   RECTUM—PRURITIS  ANI.      Ill 

rectum  is  perfect,  but  there  is  a  septum  higher  up.  lu 
other  cases  the  Avliole  rectum  is  Avanting,  and  even  some 
portion  of  the  colon.  Tliere  are  also  instances  where  the 
rectum  ends  in  the  vagina  or  in  the  bladder. 

Treatment. — Where  there    is  only  a    thin    membrane 


Fig.  41. — Impeefobate  Rectum  {Esmarch). 

closing  the  anus,  it  is  easy  to  divide  it  by  a  crucial  incision, 
and  cure  the  patient. 

If  the  rectum  stops  liigher  up,  then  we  are  in  doubt  as 
to  where  the  cul  de  sac  is  to  be  found.  It  is  proper,  how- 
ever, to  seek  for  it.  The  patient  being  anaesthetized,  an 
incision  is  made  from  the  center  of  the  spot  where  the  anus 
should  be,  directly  back  to  the  tip  of  the  coccyx.  If  the 
cul  de  sc(C  of  the  gut  is  tliere  at  all  it  will  be  in  or  below 


112  RECTAL   AND   ANAL   SURGERY. 

the  hollow  of  the  sacrum.  The  incision  is  therefore  cautiously 
made  on  the  middle  line,  close  to  the  sacrum,  and,  if  needful, 
the  coccyx  may  be  excised  to  enable  the  operator  to  get 
higher  up.  The  gut  is  felt  for  with  the  finger,  and  if  found 
is  opened,  and  if  possible  drawn  down  and  stitched  to  the 
incision  as  near  to  the  normal  location  of  the  anus  as  its 
extensibility  will  permit  without  much  tension.  In  this 
blind  search  one  feels  very  uneasy  as  he  goes  deeper.  If 
child  has  been  born  long  enough  to  generate  gas  in  the 
intestines,  the  resonant  ciil  de  sac  of  the  rectum,  if  it  exists 
there,  may  be  detected  by  jjercussion  on  the  sacrum.  We 
have  found,  also,  that  by  taking  a  small  stick,  five  inches 
long,  with  the  ends  squarely  cut  off,  and  inserting  one  end 
into  the  wound,  and  against  any  tissue  suspected  to  be  the 
end  of  the  gut,  we  can  elicit  the  tympanitic  sound  by  tapping 
with  the  finger  against  the  outer  end  of  the  stick  if  the  gut 
is  really  there.  If  the  gut  is  not  found,  then  a  lumbar  or  an 
anterior  colotomy  must  be  made  above,  in  accordance  with 
the  usual  rules  for  that  operation. 

Pruritus  Ani. — The  causes  of  this  troublesome  and 
obstinate  complaint  are  numerous.  In  the  first  place  we 
have  here  nearly  all  the  itching  skin  diseases  which  may 
occur  elsewhere,  such  as  eczema  simplex,  eczema  marginatum, 
erythema  and  herpes,  and  without  going  into  tedious  details, 
we  may  refer  the  reader  to  any  modern  treatise  on  skin  dis- 
eases for  the  description  and  diagnosis.  Owing  to  the  great 
sensitiveness  of  the  anal  verge,  itching  of  the  part  is  apt  to 
have  a  greater  intensity  than  elsewhere.  Those  skin  diseases 
which  are  due  to  a  fungoid  parasite,  such  as  the  tricophyton, 
etc.,  need  careful  diagnosis  by  the  microscope  in  order  to 
determine  their  character. 

A  frequent  cause  of  pruritus  is  the  presence  of  pin 
worms,  or  oxyuris  vermicularis,  in  the  rectum.  These  pro- 
duce most  trouble  in  the  evening.  They  may  often  be  found 
with  the  speculum,  but  the  surest  way  is  to  watch  the  suc- 
cessive evacuations  for  some  time.     In  some  cases  they  seem 


MALFORMATIONS    OF   THE   RECTUM— PRURITUS   ANI.      113 

to  be  easily  cured  by  varioiis  remedies,  but  in  others  they 
are  never  all  exterminated,  and  though  made  seemingly  to 
disappear  for  a  few  weeks  or  months,  yet  they  multiply  again, 
and  require  occasional  treatment  throughout  life.  Pediculi 
are  sometimes  the  cause  of  the  itching. 

Pruritus  ani  is  frequently  a  neuralgic  trouble,  caused 
by  irritation  in  other  parts.  For  instance,  little  ulcers  or 
inflamed  spots  among  the  sacculi  Horneri,  just  above  the 
verge,  frequently  cause  great  itching  of  the  verge  itself. 
Internal  piles  at  the  same  level  may  have  a  similar  effect. 

It  is  curious,  also,  that  stricture,  and  inflammation  of 
the  upper  portion  of  the  urethra,  sometimes  cause  rectal 
itching.  In  other  cases  it  appears  to  be  due  to  some  lesion 
of  the  sensory  nerve  fibers  surrounding  the  verge,  for  it 
yields  to  the  nerve  stretching  produced  by  a  forced  dilatation 
of  the  anus. 

In  other  instances  it  is  directly  or  indirectly  due  to 
disease  of  the  spinal  cord  and  brain. 

Finally,  it  may  be  caused  by  depraved  and  irritating 
secretions  sent  down  by  the  rectum,  colon,  or  higher  bowels. 

Treatment. — The  first  step  is  a  complete  examination 
of  the  parts  externally  and  internally.  We  thus  ascertain  if 
there  is  any  eruption  of  the  skin,  any  ulcers,  inflammations 
or  haemorrhoids  present.  Ascarides  and  pediculi  are  to  be 
searched  and  watched  for.  In  males  the  question  of  stricture 
or  other  causes  of  irritation  in  the  upper  half  of  the  urethra 
are  to  be  decided.  If  eczema  is  present,  it  may  require 
arsenic  internally  and  local  treatment  externally,  as  in 
eczema  of  other  localities.  If  tricophyton  or  other  parasitic 
fungi  are  found,  they  must  be  destroyed.  If  ulcers,  inflamed 
spots,  fistulas  or  internal  piles  exist,  they  must  be  radically 
cured.  If  stricture  of  the  male  urethra  is  found,  or  cystitis 
in  either  sex,  these  diseases  must  be  removed.  Constitutional 
disorders  must  also  be  treated,  constipation  corrected,  and 
good  digestion  secured.     If  no  constitutional  or  local  dis- 


114  RECTAL   AND   ANAL   SURGERY. 

eases  are  found,  the  itching  is  probably  a  neurosis.  If  due 
to  disease  of  the  brain  or  spinal  cord  these  organs  are  to  be 
treated;  if  to  tlie  nerves  themselves  surrounding  the  anus, 
the  dilatation  of  the  anus  should  be  tried. 

Local  applications  are  often  successful,  and  yet  in  many 
cases  they  totally  fail.  It  is  well  to  have  a  good  list  of  them 
for  trial. 

In  case  of  pediculi,  mercurial  ointment  is  sufficient.  If 
ascarides  are  present,  a  Aveak  solution  of  carbolic  acid 
injected  into  the  rectum  at  evening  is  at  least  a  temporary 
help.  After  trying  varied  vermifuges,  we  find  that  sulphur 
given  internally  seems  to  be  one  of  the  best  destroyers  of 
the  worms,  but  it  does  not  make  absolutely  complete  work. 
It  should  be  followed  by  some  purgative  containing  rhubarb 
and  aloes,  or  other  stimulants  to  the  mucous  follicles  of  the 
lower  bowel.  Whenever  the  patient  has  a  pretty  complete 
emptying  of  the  bowels  with  free  discharge  of  rectal  mucus, 
he  invariably  remains  free  from  trouble  for  a  considerable 
period,  as  the  habitat  of  the  worms  is  in  the  mucus,  and 
mucus  evacuations  sweep  them  out  more  effectually  than  any 
others. 

When  the  microscopic  fungi  are  the  cause,  sulphur, 
sulphurous  acid,  bichloride  of  mercury,  and  iodine  can  all  be 
used  in  quantities  and  strength  adapted  to  the  case.  Dr. 
Carson  ''cuts"  a  drachm  of  camphor,  in  a  trifle  of  alcohol, 
and  then  rubs  it  up  in  an  ounce  of  lard,  and  looks  upon  it  as 
almost  a  specific,  if  well  rubbed  upon  the  anus,  and  also  put 
into  the  rectum.  In  all  cases  the  parts  should  be  Avell 
washed  with  soap  and  hot  water  before  applying  the  local 
remedies, — and  in  many,  a  washing  out  of  the  rectum  with 
the  same,  through  a  double  canula,  is  also  necessary.  When 
simple  chafing  is  the  cause  of  pruritus,  a  powder  of  sub- 
nitrate  of  bismuth,  precipitated  chalk  and  starch,  is  curative. 

Compresses  of  hot  water,  as  hot  as  they  can  be  borne, 
relieve    many.      Compound   tincture    of   green    soap,    made 


MALFORMATIONS   OF   THE  RECTUM— PRURITUS  AN  I.      115 

according  to  the  following  formula,  is  added  by  Kelsey  to 
the  hot  water  compresses. 

li      Saponis  viridis,  1 

01.  cadini,  \ ^^  zy 

Alcohol,  \ 

Misce. 

The  following  are  useful: 

I^      Chloroformi fl.   -i_ 

Ung.  oxid.   zinc ^j. 

Misce. 

1^      Mur.  cocaine gr.  xv. 

"      morph gi*-  X. 

Acid  carbol.  cryst 3i. 

Tinct.  aconiti  rad fl.  3iij. 

Unguent,  petrolii 3J. 

Misce. 

This  must  not  be  inserted  inside  the  verge  in  large  doses. 

AUingham  highly  praises  the  following: 

I^     Liquor,  carbon,  detergentis  (Wright's) .  .  .  fl.  3 j 

Glycerinte fl.  =i. 

Zinci  oxid  pulv., 


Calamin.  prep.,         \ '   ■^^^' 

Sulphuris  precip.  pulv rss. 

Aqu3e  pur ^vi. 

Misce. 

Also  this  by  the  same  author: 

I^      Sodse  borat 3ij. 

Morph.  hydrochlor gr.  xvi. 

Acid,  hydrocyan.  dilut fl.  rss. 

Glycerinse fl.  rfj. 

Aquje fl.  5viij. 

Misce. 


116  RECTAL   AND   ANAL   SURGERY. 

Kelsey  advises  this: 

Ijt      Acid,  carbol 5^^- 

Glycerinse fl.   3J. 

Aquae fl.  siij. 

Misce. 
It  is  ])retty  strong,  aud  often  requires  to  be  diluted. 

Kekey  also  advises  the  following: 

I^      Chloral 3j. 

Camphorse 3j. 

Ung.   petrol 3J- 

Misce. 

1^      Menthol 3j. 

01.  amygd.  dulc fl.  3 j. 

Acid  carbol 3j. 

Zinc,  oxid 3ij. 

Cerat.  simp "ij. 

Misce. 

li      Ung.   picis 3iij. 

"        belladon 3ij. 

Tr.  aconiti  rad fl.  3ss. 

Zinci  oxid 3j. 

Ung.    rosarum 3iij. 

Misce. 

When  any  of  these  are  found  too  strong  they  require  to 
be  diluted  or  weakened.  Those  containing  powerful  nar- 
cotics must  not  be  inserted  in  too  large  doses  into  the 
rectum. 

Allingham  finds  that  the  mechanical  pressure  of  a  hard 
pad  bound  against  the  anus,  or  the  insertion  of  a  smooth 
hard  rubber  plug  into  the  rectum  is  a  substantial  relief  to 
some  patients. 

Nerve  Stretching. — A  sort  of  nerve  stretching  accom- 
plished by  forcibly  dilating  the  sphincters  has   a  curative 


MALFORMATIONS   OF   THE   RECTUM—PRURITUS   ANI.      117 

effect  on  some  obstinate  cases  of  pruritus,  which  are  probably 
to  be  classed  as  neuroses. 


Fig.  42. — Nebve  Distkibution  about  the  Anus. 

1.  Sacral  Nerves;  posterior  root  distributed  to  surface  of  coccyx  and  external  sphinc- 
ter. 2.  Anterior  root,  to  external  sphincter.  3.  Pudic  nerve  and  its  branch,  the  inferior 
hiemorrhoidal.  t.  Tub.  ischii.  s.  Sacrum,  c.  Coccyx.  Sp.  Ext.  sphincter.  I.  Levator 
ani.     p.  Transversus  periuei.     ri.  Ischio-rectal  space. 


The  cut  on  this  page  (after  Hilton)  gives  a  clear  repre- 
sentation of  the  local  nerve  distribution. 


CHAPTER    XIII. 
MECHANICAL     INJURIES. 

Incised  Wounds. — These  may  be  caused  by  accident, 
or  be  a  necessary  result  of  operations.  Owing  to  the  loca- 
tion, purely  accidental  incisions  are  rare.  A  part  of  them 
are  made  by  surgeons  acting  carelessly  in  the  operation  of 
lithotomy.  They  occur  also  from  stabs  and  falls  on  sharp 
objects.  The  incision  bleeds  freely,  and  may  do  so  danger- 
ously. The  gas,  mucus  and  faeces  also  escape  through  the 
wound,  and  when  the  accident  occurs  in  lithotomy  urine  also 
flows  out  at  every  micturition.  The  lithotomy  cases  are  not 
very  uncommon,  and  have  occurred  in  the  practice  of  nearly 
all  the  world's  great  lithotomists.  Most  of  them  heal  spon- 
taneously, but  a  few  of  them  result  in  obstinate  recto- 
urethral  fistulas.  There  is  also  danger  from  peritonitis  if 
the  peritoneum  is  wounded,  and  of  septic  cellulitis  and 
abscesses  if  faecal  effusion  takes  place  into  the  connective 
tissue. 

Treatment. — Incised  wounds  of  the  rectum  which  sim- 
ply cut  across  the  sphincter  into  deeper  parts,  but  do  not 
injure  important  organs,  if  seen  early,  may  be  closed  with 
sutures  as  in  other  incised  wounds.  If  the  weapon  has 
entered  like  a  stab,  tunnelling  into  the  rectum,  and  therefore 
leaving  the  sphincter  undivided,  and  is  seen  early,  it  may  be 
sewn  up  on  the  rectal  side  in  hope  to  get  a  union  by  first 
intention.  If  some  days  have  elapsed  since  the  wound,  it  is 
now  a  fistula  and  must  be  treated  as  directed  in  the  chapter 
on  that  subject. 

The  rectal  wounds  made  in  lithotomy  are  sometimes 
among  the  most  annoying  of  cases.     True,  they  often  heal 

118 


MECHANICAL   INJURIES.  119 

spontaneously,  but  if  tliey  fail  of  that,  they  become  recto- 
urethral  fistulas  which  often  resist  repeated  operations. 
When  the  accident  first  occurs,  there  is  no  doubt  that  the 
incision  would  have  the  best  chance  if  closed  at  once  by 
sutui'es  on  the  rectal  side,  but  the  lithotomist  rarely  has  the 
requisite  instruments  with  him  at  the  time,  and  the  oppor- 
tunity passes  by.  Most  authors  write  on  this  subject  like 
perplexed  men,  but  generally  agree  reasonably  well  on  the 
following  course: 

If  the  primary  operation  for  closing  the  incision  has 
failed,  or  not  been  attempted,  take  plenty  of  time  for  expect- 
ant treatment,  which  results  in  the  spontaneous  cui'e  of  the 
majority  of  cases.  The  wound  should  be  kept  clean,  the 
rectum  kept  empty,  and  a  sheaf,  consisting  of  three  large 
soft  rubber  catheters,  kept  in  the  anus  for  drainage,  that 
there  may  be  no  pressui'e  of  gas  or  mucus  in  it  to  force  open 
the  contracting  fistula. 

If  this  fails,  and  the  remaining  opening  is  very  small 
and  high  up,  success  vnll  sometimes  be  obtained  by  electro- 
cautery of  the  internal  orifice,  and  the  re-introduction  of  the 
sheaf  of  catheters.  If  this  fails,  or  if  the  opening  is  both 
large  and  high  up.  then  anaesthetize  the  patient,  make  a  wide 
dilation  of  the  rectum,  and  operate  on  the  part  as  in  vesico- 
vaginal fistula.  The  operation  is  somewhat  difficult,  and  not 
sure  of  success.  It  is  well,  in  some  cases,  to  vary  it  by  rais- 
ing a  flap  of  mucous  membrane,  and  sliding  it  across  the 
refi'eshed  opening,  stitching  it  to  its  new  place.  If  this  also 
fails,  our  best  authors  are  silent  as  to  what  should  be  done 
next.  Apparently,  they  are  in  despair,  so  far  as  these  upper 
fistulas  are  concerned.  In  the  lower  ones,  however,  where 
the  orifice  is  down  near  the  sphincter,  if  plastic  operations 
fail,  success  is  pretty  sure  by  simply  cutting  the  fistula 
through  into  the  gut,  as  in  ordinary  fistula  in  ano.  and  treat- 
ing the  wound  as  usual  after  that  operation.  Our  opinion 
is  that  a  bold  extension  of  this  plan  to  the  higher  fistulas 
would  succeed,  with  some  modifications  to  adapt  it  to  the 


120  RECTAL   AND   ANAL  SURGERY. 

locality.  We  have,  however,  not  yet  had  occasion  to  test 
this  opinion  in  actual  practice. 

When  an  incised  wound  has  opened  the  peritoneal  fold, 
it  shouhl  ])e  freely  opened  and  explored,  and  the  peritoneal 
rent  sewed  up.  If  blood  and  fseces  have  escaped  into  the 
cavity,  they  should  be  immediately  washed  out,  even  if  a 
regular  laparotomy  has  to  be  performed  for  the  purpose. 

Punctured  and  Lacerated  Wounds  of  the  Rectum. — 
These  are  the  result  of  various  accidents,  such  as  farmers 
sliding  from  haymows  upon  pitchforks  or  sharp  stakes,  falls 
among  crushed  and  broken  timbers,  and  goring  by  the  horns 
of  cattle. 

They  are  considerably  dangerous  when  they  lead  to 
the  effusion  of  the  rectal  contents  into  the  loose  connective 
tissue.  In  such  cases  they  require  free  openings  below  for 
washing  and  drainage,  and  especially  a  thorough  division  of 
the  sphincter,  and,  if  the  peritoneal  cavity  is  opened,  cleans- 
ing, sewing  up,  and  possibly  laparotomy  may  be  required, 
just  as  in  incised  wounds. 

Gunshot  Wounds. — These  are  decidedly  dangerous,  not 
so  much  from  the  injury  to  the  rectum  itself,  as  from  the 
wounding  of  the  other  organs  by  the  same  bullet.  The 
Surgeon  General's  "  History  of  the  AVar  of  the  Rebellion" 
gives  305  cases,  with  44  deaths. 

In  many  of  these  cases  there  is  great  effusion  of  rectal 
contents  into  the  connective  tissue,  and  sometimes  into  the 
peritoneal  cavity.  The  urinary  passages  also,  may  be 
wounded,  and  contribute  a  deadly  addition  to  the  putrefying 
mass. 

These  cases  require  prompt  action.  It  is  well  to  extract 
the  bullet,  if  possible,  but  that  is  not  the  chief  thing. 
Hsemorrhage  must  be  stopped,  if  troublesome,  by  any  and 
all  of  the  usual  methods.  Dr.  Bushe  long  ago  devised  a 
cold  compressor.  A  bladder  was  attached  to  a  double  tube 
in  such  a  way  that  it  could  be  inserted  into  the  rectum,  and 
strongly  distended  with  ice  water. 


MECHANICAL   INJURIES.  121 

Dupuytren  also  called  attention  to  the  importance  of 
preventing  septic  infiltration  by  such  a  thorough  division 
of  the  sphincters  as  would  insure  a  free  downward  di'ainage. 
At  a  later  period.  Simon,  of  Heidelberg,  wrote  a  paper  of 
great  merit,  strongly  enforcing  the  same  measure,  and  the 
whole  experience  of  the  Avorld  to  this  hour  emphasizes  these 
three  precepts: 

1.  Divide  the  sphincter,  in  most  cases,  up  to  the  track 
of  the  bullet,  and  keep  the  wound  wide  open. 

2.  Make  other  free  incisions  wherever  needed. 

3.  Irrigate  thoroughly  with  antiseptics. 

In  these  ways  the  mortality  of  these  serious  wounds 
may  be  reduced  to  the  lowest  rate  permitted  by  the  con- 
comitant injuries. 


APPENDIX  AND  FORMULARY. 

1.  Contracf  of  "  Rectal  Specialist." 

The  following  is  an  exact  copy  (personal  items  being 
omitted)  of  a  contract  to  cure  piles  shown  us  by  a  patient 
who  was  still  suffering  from  that  affection.  The  method 
used  by  the  guarantor  of  the  cure  had  been  the  hypodermic 
injection  and  the  relief  obtained  had  continued  a  number  of 
years. 

I  hereby  agree  to  pay  to  Dk. &  Co.  the  sum  of 

[25  dollars] to  cure  me  of [pz'Zes] 

ivith  which  disease  I  am  afflicted.      The  above  amount  to  be  paid 

to  Dk. &  Co.   as  soon  as   cure   is    effected.      Cure 

agreed  to  be  complete  ivhen  the [tumors  are  removed^ 

/  further  agree  to  go  to  the  office  of  Dk. &  Co. 

and 

submit  to  treatment.  Should  I  neglect  or  refuse  to  go  and  sub- 
mit to  treatment  as  above  agreed,  without  some  providential 
hindrance,  then  the  above  shall  become  due  and  payable  the  same 

as  if  I  had  been  cured. 

[Signed^ . 

Rec'd  payment 

The  use  of  such  contracts  is  not  only  unprofessional, 
but  does  nothing  toward  raising  an  operator  in  the  estima- 
tion of  intelligent  patients. 

2.  For  use  upon  instruments  and  lingers. 

1^      Acid,  boric 3ss — j 

Ung.  petrol ~j 

M.     Keep  in  collapsible  tubes. 

3.  For  instruments  and  fingers. 

I)t      Acid,  carbol gr.  xxv. 

Ung.  petrol 3J. 

M.     Keep  in  collapsible  tubes. 
122 


APPENDIX  AND   FORMULARY.  123 

4.  For  acute  proctitis. 

I^      Mucilage  of  starch Hj 

Tr.   opii x-xxx 

5.  For  acute  proctitis. 

IJ,     Iodoform ~i 

Ext.  belladon gr.  v 

Pulv.  opii gi"-  X 

01.  theobroui q.  s. 

M.     Ft.    Suppositories    No.    XII. 

6.  For  acute  proctitis. 

IJ      Liq.  carbonis  detergent "ii 

Tr.  kramerise 3iv 

Mucil.  amyli q.  s.  ad.  jiv 

M.  Liq.  Inject  fi  morning  and  night. 

7.  For  acute  proctitis. 

I^     Liq.  bismuth 3i 

Mucil.  amyli jvi 

8.  For  acute  proctitis  (Dr.  J.  M.  Matthews,  Louisville). 

J^      Sub-nit.  bismuth 3j 

Iodoform gi'-  x 

Sweet-almond  oil 3 j 

M.    S. — Inject. 

I^      Fluid  hydrastis 3j 

Aquae 3J 

M.    S.— Inject. 

I^      Listerine, 

Aqua; aa    3  j 

M.    S. — Inject. 

9.  For  chronic  proctitis. 

I^      Argent,  nit gi'-  v. 

Aq.  dest fij 

To  be  injected  and  removed  by  a  subsequent  enema. 


124  RECTAL   AND   ANAL  SURGERY. 

10.  For   hsemoiThoids    (where  it  is  desired  to  confine  the 

bowels  after  operation. — Allingham). 

I^      Pulv.  cretjp.  aroniat 3j 

Tr.  opii.  or  li({.  opii.  sedativ.  rq  xv 

Spts.  fetb.  nit, 3j 

Mist,  camphorpe ;iss 

M.  S. — To  be  taken  night  and  morning  for  two  or  four  days. 

11.  For  haemorrhoids  (laxative). 

I^     Magnes.  sulph. 
Magnes.  carb. 
Sulphur  jirecipitat. 

Sacch.  lactis afi  5ss 

Pulv.  anisi 3ij 

M.     S.     One  or  two  teaspoonfuls  in  water  at  night  (Prof.  G. 
T.  Elliot). 

12.  For  haemorrhoids  (laxative,  ^'■Pil  qiiatfiior.''^  Van  Buren. ) 

1>      Ferri.  sulph.  exsiccat. 

Quinine  sulph ail    3  ij 

Ext.  nuc.  vomicae. 

Ext.   aloes fia  gr.  xij 

M.  Ft.  pil.  No.  XL.     S.  One  three  times  a  day. 

13.  For  haemorrhoids  (laxative,  "Pv7  salidis^''  ). 

P^      Ext.  aloes. 

Ext.  hyoscyami aa  3j 

Ext.  nuc.  vomicae gr.  iv 

01.  anisi gtt.  iv 

M.    Ft.  pil.  No.  LX. 

14.  For  haemorrhoids,  with  ulceration  (Allingham). 

1^     Bismuth,  sub-nit 3ij 

Hydrarg.  chlor.  mit 3  ij 

Morph.  sulph I^^^-  iij 

Glycerinse 3ij 

Ung.  petrol 3 j 

M.    S.     Use  in  pile  syringe. 


APPENDIX   AND   FORMULARY.  125 

15.  For  li?emorrlioids, 

l)t      Acid,  tannic 3ij 

Ext.  belladon. 

Pulv.  opii ajl  3ss 

Ung.  petrol,  (or  lanolin) 3J 

M.     S.     Apply  inside  and  outside. 

16.  For  haemorrhoids. 

1^      Cocaine  hydrochlor gi'-  ^ 

01.  Theobrom q.  s. 

M.    Ft.  suppositories  No.  XV. 

17.  For  haemorrlioids  (Ball). 

3      Morph.  hydrochlor gi'-  ^ 

Ext.  belladon. 

Acid,  tannic aa  3j. 

Vaselin. 

Lanolin 3,a  3 j 

M. 

18.  For  eczematous  external  haemorrhoids  (Ball). 

1^      Liq.  carbonis  detergentis .  .  .  .  :  j 
Liniment,  calcis 3V 

19.  For  inflamed  external  haemorrhoids  (Yount). 

IJ      Cocaine  hydrochlor g^"-  ^ 

Ext.  belladon. 

Ext.  opii. 

Ext.  aconite. 

Ext.    stramonii aa  3ii 

Glycerinse 3ss 

M.  S.  Apply  on  cotton  or  lint  continuously. 

20.  For  haemorrhoids. 

I^      Plmnbi  subacet. 

Bals.  Peru. 

Ext.  belladon. 

Zinci.  benzoat aa  3j 

Adipis 3J 

M. 


126  RECTAL   AND   ANAL   SURGERY. 

21.  For  htemoiTlioids  (with  tenesmus). 

1:J     Pulv.  opii. 

Ext.  belladon a<1  gr.  x 

01.  Theol)rom q.  s. 

M.     Ft.  suppositories  No.  XV. 

22.  For  hypodermic  treatment  of  haemorrhoids. 

I^     Acid,  carbol.  (crystals)  gr.  xx — 3ij 

Glycerinse q.  s. 

Aq.  dest ({.  s.  ad  5j 

M. 

23.  For  hypodermic  treatment  of  haemorrhoids. 

1$      Acid,  carbol.  (crystals) .  .  3ij — 3iv 

Glycerinse q.  s.  ad  3 j 

M. 

24.  For  hypodermic  injection  of  hsemorrhoids    (not  much 

used). 

5     Acid  carbol.  (crystals) ...  95  per  cent. 

Aq 5  per  cent. 

M.     S.     95  per  cent.  sol.  carbolic  acid. 

25.  For    hypodermic     treatment    of     haemorrhoids     (early 

formula ) . 

I^     Acid  carbol.  (crystals  melted) .  Zj — 3v 

01.  olivse .  .  .  .  q.  s.  ad  3 j 

M. 

26.  For  hypodermic  treatment  of  haemorrhoids  ("Brinker- 

hofP  System"). 

I^      Carbolic  acid 3J 

Olive  oil 3V 

Chloride  of  zinc grs.  viij 

Mix. 

The  little  pamphlet  furnished  to  the  itinerants  purchasing 


APPENDIX   AND   FORMULARY.  127 

the  "  System  "  directs  that  the  amount  of  injection  inserted  into 
the  tumors  shall  be  as  follows: 

Largest  Piles 8  minims 

Mediiim     •'     4  to  8       " 

Small  "     2  to  3      " 

Club-shaped  painless  piles  near  orifice       2       " 

"  Brinkerhoff's  System "  forbids   the  injection   of   any  but 
internal  piles. 

27.  For   hypodermic    treatment  of   hsemorrhoids   ("Rorick 

System"). 

I^     Carbolic  acid. 

Glycerinse ^^  ~U 

Fi.  ext.  ergot 3j 

Water 3iss 

Mix. 

28.  For  hypodermic  treatment  of  haemorrhoids  ("Painless 

injection"  of  Dr.  Green,  a  traveling  pile  doctor). 

I^      Carbolic    acid 3J 

Creosote gtt.  x 

Acid,  hydrocyanic gtt.  j 

Olive   oil fi 

Mix  and  unite  under  water.     Sig.     Inject  enough  to  turn 
the  tumor  an  ashen  grey  color. 

29.  For  hypodermic  treatment  of  haemorrhoids.      (Dr.  Silas 

T.   Yount  of   Lafayette,   Ind.,    advocates  very  weak 
injections,  viz).  * 

5      (5  per  cent.  sol). 

Acid,  carbol gr.  xxiv 

Aq.  dest 5 j 

M. 

IJ      (3  per  cent.  sol). 

Acid  carbol gr.  xviss 

Aq.   dest 3J 

M. 


128  RECTAL   AND   ANAL   SURGERY. 

SO.   For  fistula  (Itinerant  method), 

1^      (First  ste])) 

Hydrogen  pex'oxide 3j — "iv 

Aq q.  s.  ad  5j 

M.     S.     iQJect  the  listula  deeply. 

81.  Ijt      (Second  step) 

Acid  carbol gr.  xl — 3j 

Glycerine  or  alcohol q.  s. 

Aq (J.  s.  ad  3  j 

M.  S.  Inject  15  drops  after  the  hydrogen  bubbles  have 
ceased. 

Or  (BrinkerhofP) 

32.  Ij.     Dist.  ext.  hamamelis fl.  3v 

Liq.  fer.  subsulph fl.   3j 

Acid,  carbol.  cryst gr.   ij 

Glycerinse fl.   3ij 

M.  S.  Inject  ten  or  fifteen  drops  deeply  into  the  fistula, 
and  press  the  track  of  the  fistula  with  the  finger,  to  force  the 
fluid  more  deeply  in. 

Many  itinerants  finish  the  operation  two  hours  later  by 
injecting  the  fistula  with  equal  parts  of  oil  of  eucalyptus 
and  glycerine. 

33.  For  fissure  of  the  anus. 

I^      Corrosive  sublimate gr.  j 

Cryst.  carbolic  acid 3  ij 

Hydrochlorate  of  morphia .  gr.  v 

Water fl.   z^'v 

M.     S.     Apply  with  a  camel's  hair  pencil. 

34.  For  fissure  (Allingham). 

I^     Hyd.  sub.  chlor g^"-  iv 

Pulv.  opii g^-  ij 

Ext.  belladon gr-  ij 

Ung.  sambuci 3 j 

M.     Sig.     Apply  several  times  a  day. 


APPENDIX   AND   FORMULARY,  129 

35.  For  fissure. 

^,     Hydrarg.  oxid.  flav gr.  xxx 

Ung.  petrol 3! 

36.  For  fissure. 

5     Iodoform 3j 

Belladonna   ointment ^^s. 

Carbolic  acid gi*-  ^ 

Simple  cosmoline ^ss 

M. 

Apply  this  ointment  thoroughly  every  day,  after  having  each 
time  cleansed  the  sore  vs^ith  antiseptics,  and  touch  with  nitrate  of 
silver  very  gently  every  third  day. 

37.  For  rectal  ulcers  (see  also  Nos.  4,  5,  6,  7,  8,  9). 

5     Argent,  nit gr-  ij 

Aq.    dest ;  j 

M.     S.     Inject  and  wash  out  with  warm  water. 

38.  For  rectal  ulcers. 

5      Iodoform 3ss 

Bismuth,  subnit 3 j 

Morph.  sulph gr.  j 

01.    theobrom q.  s. 

M.     Ft.  Suppositories  No.  X.     S.     Insert  one, 
morning  and  night. 

39.  For  prolapsus  (Itinerant  method). 

IJ     Cocaine  hydrochlor. 

Phenol  sodique aa  gr.  viij 

Aq 3J 

M.  S.  Inject  in  spots  one  inch  apart  over  the  tumor. 
("  Brinkerhoff's  system "  advises  its  followers  to  avoid  treating 
prolapsus). 

40.  For  prolapsus  (Vidal  de  Cassis). 

I)!,     Ext.  ergot,  fl nqx — lx 

S.     Inject  with  hypodermic  syringe. 


130  RECTAL  AND   ANAL   SURGERY. 

41.   For  pruritus  ani  (parasitic  form). 

I^      Camphor. 

Spts.  rectif iia,  3j 

Adipis 3  j 

M.     S.     Inside  and  outside  the  rectum. 


42.   For  pruritus  ani  (Kelsey). 

I^      Saponis  viridis. 

01.  cadini. 

Alcohol '''^''^5.] 

M. 


43.   For  pruritus  ani. 

I^      Chlorof ormi fl.   3 j 

Ung.  oxid.  zinc 3 j 

M. 


44.  For  pruritus  ani. 

IJ     Mur.    cocaine gr.  xv 

Mur.    morph gr.  x 

Acid   carbol.   cryst 3 j 

Tinct.  aconiti  rad A-  "iij  ^ 

Unguent   petrolii 3] 

M.  > 

This  must  not  be  inserted  inside  the  verge  in  large  doses. 


45.  For  pruritus  ani  (AUingham). 

I^      Liq.  carbon,  deter.   (Wright's),  .fl.  3J 

Glycerinse A-  ^  j 

Zinci  oxid.  pulvi, 


„  T       .  ,    aa  3SS 

Calamin.  prep., 

Sulphuris  precip.  pulv 3SS 

Aqu?e    pur 3VJ 

M. 


APPENDIX  AND   FORMULARY.  131 

46.  For  pruritus  ani  (Allingliam). 

I^      Sodae  biborat 3ij 

Morph.  hydrochlor gr.  xvi 

Acid,  hydrocyan.  dilut . .  .  .  fl.  3SS 

Glycerinse 11.   ^ij 

Aquse il.    3viij 

M. 

47.  For  pruritus  ani  (Kelsey). 

I^     Acid  carbol 3ss 

Glycerinse A-  j j 

Aquae H.  3iij 

M. 

It  is  pretty  strong,  and  often  requires  to  be  diluted. 

48.  For  pruritus  ani  (Kelsey), 


^     Chloral 3j 

Camphorse 3j 

Ung.  petrol f  j 

M. 


49.  For  pruritus  ani. 


5     Menthol 3  j 

01.  aniygd.  dulc fl.   3 j 

Acid,  carbol 3j 

Zinc,    oxid 3ij 

Cerat.   simp . .  .  j 3ij 

M. 


50.  For  pruritus  ani. 


5     Ung-  picis 3iij 

Ung.  belladon 3ij 

Tr.  aconiti  rad fl.  3ss 

Zinci  oxid 3j 

Ung.  rosarum 3iij 

M. 


132  RECTAL   AND   ANAL  SURGERY. 

51.  For  pruritus  ani. 

]^     Ext.  conii  (freshly  made)  .  .  . .  3j 

Lanolin 3ij 

M. 

52.  For  pruritus  ani  (with  external  eruptions). 

IjL     Acid,   salicy] gr-  x 

Spts.  rectif 3J 

M. 


INDEX 


A  PAGE 

BSCESS  near  rectum         ---...  57 

Aetius,         ---------  67 

Allingham,        -  -    9,  17,  27,  30,  32,  36,  49,  57,  59,  86,  105,  115,  124,  131 

Amyloid  disease  in  rectum,      ------  47 

Antiseptic  tubes  for  vaseline,        -             -             .             -             -             -  18 

Anus,  fissure  of,             -------  67 

fistula  of       -             -             -             -             -             -             -             -  59 

imperforate,       -------  no 

pruritus  of,               .---.-.  112 

Arteries  of  rectum,      -------  g 

Ascarides,                 ----_...  113 

Ashton,               -.---...  28 
Ashurst,                    -             -             -             -             -             -             -              28,  54 


B. 


)ALL,  -------  50,  69,  125 

Bible,  the,  on  haemorrhoids,  -  -  -  -  -  -        21 

Billings,  -----.-.  52 

Billroth,      ---------      105 

Bistoury,  "  royal,"       -------  63 

Blondin,     ---------  2 

Bodenhamer,  -  -  -  -  -  -  16,  28,  67 

Boyer,         -  -  -  -  -  -  -  -        78,  71,  73 

Bright's  disease,  -------  28 

BrinkerhofiE,  -  -  -  -  -  -  36,  65,  125,  131 

Brodie,  --------  28 

Bumstead,  ----.,..       43 

Bushe,  -  -  -  -  \  -  -  -  -      28,  120 

Cancer  of  rectum,  --.--_  loi 

colotomy  for,  .  -  .  .  -  107 

diagnosis  of,  -  -  -  -  -  -  102 

palliative  measures  for,  .  -  -  .  -  106 

treatment  of,         ------  -      107 


c 


ARTILAGINOUS  tumors  of  rectum,        -  -  -       89,  98 

Celsus,        ---------        27 

Census,  U.  S.,  on  distribution  of  cancer,     .  -  -  -  101 

Circular  excision  (Whitehead's  operation),         -  -  -  -        41 

Clamp  and  cautery,    -------  37 

133 


134  INDEX. 

PAGE 

Collapsible  tube  for  vaseline,       -  -  -  -  -  -       13 

Cocaine,  use  of,  -  -  -  -  -  28,  66,  93 

Colotomy,  lumbar,  ------  96,  101 

Columns  of  Morgagni,  --..-.  3 

Condylomata,        -  -  -  •  -  -  -  48,  89 

Connective  tissue  of  rectum,  -  -  -  -  -    5 

Contraction,  spasmodic,  of  anus,  -  -  -  -         67,  70,  99 

Cooper,  ..--.---  28 

Copeland,  -  -  --  -  -  -  -28 

Cripps,  -------  28,  101,  105 

Crushing  piles,      --------        39 

Curling,  ..-.--.-  68 

Curshmann,  -.----..        72 

Cusach,  .--.-.--  37 

Cystic  tumors  of  rectum,  -  -  -  -  -  -        89 


D. 


'AVISON,     --------  93 

Digital  examination,          -             -            -             -             -             -  -      13 

Dilator,  rectal,  Davison's,        ------  93 

Sargent's,                -              -             -             -             -  -      93 

Wales',              ------  93 

Diphtheria  of  rectum,        -             -             -             -             -             -  -      47 

Displaced  organs,  obstruction  from,               -             -             -             -  98 

Dupuytren,  -  -  -  -  -  -  -       2,  68,  121 

Duret,                 -             -             -             -----  23 

Dysentery,               -             -             -             -            -             -             -  -      47 

IjCRASEUR,  Andrews',               -             -             -             -             -  -      39 

in  cancer,         ------  105 

for  piles,    -             -             -             -             -             -  -      39 

in  proctotomy,             -----  66 

Nott's,        -             -             -             -             -             -  -      41 

Smith's  wire,  ------  40 

Elliot,  ---------     124 

Erectile  property  of  haemorrhoids,     -----  24 

Esmarch,      -  -  -  -  -  -  53,  60,  63,  81,  106,  110 

Examination  of  rectum,           ------  9 

digital,                  -            -             -             -            -  -      13 

electric  lamp  for,      -----  12 

by  external  inspection,               -             -             -  -      12 

light  for,        ------  11 

positions  for,      -             -             -             -             -  -       10 

questions  for,             -----  10 

whole  hand  in,    -             -             -             -             -  -      15 

sounds  in,      -            -             -             -             -             -  14 


INDEX.  135 

FFAOE 

^CES.  impaction  of,           ------  99 

Fatty  tumors  of  rectum,    -             -             -             -             -             -  -      89 

Ferguson,           --------  2 

Fibrous  tumors  of  rectum,             -             -             -             -             -  -      89 

Fistula  in  ano,               ------  59 

"  horseshoe,"           -             -             -             -             -             -  -      61 

treatment  of,    -             -                                          ^       -             -  62 

itinerant  treatment  of,      -             -             -             -             -  -      64 

urinary,             .             -             -             .             -              .             -  62 

UTLANDS,  inguinal,  enlargement  of,             -             -             -             -  12 

Gonococcus,  diagnosis  by,              -             -             -             -             -  -      48 

Gonorrhceal  proctitis,               -...--  46 

Gosselin,     .             .             -             -             ....  -      68 

Gowlland,           --------  28 

Gronj,         ---------        2 

Gross,        -                       -             -             -             -             -             -             -  28,  54 


rl ^MORRHAGE,  means  of  controlling,            -                           -  -      32 

Haemorrhoids,               -             -              -----  21 

Bible  allusions  to,  -             -             -             -             -  -      21 

causes  of,  -  -  -  -  -  -21 

classification  of,     -            -            -             -            -  -      23 

clamp  and  cautery  in,               -             -             -             -  37 

circular  excision  of,                          -             -             -  -      41 

^craseur  in,       -             -             -             -             -             -  38 

erectile  property  of,           -             -             -             -  -      24 

excision  of,        -             -             -             -             -  40 

forced  dilatation  for,                       -             -             -  -      26 

itinerant  treatment  of,             -             -             -             -  30 

hypodermic  injection  of,                            -             -  -      33 

ligature  in,        -             -  \           -             -             -             -  27 

palliative  measures  for,     -             -             -             -  -      25 

Hamilton,          --------  28 

Hand  in  rectum,     -                           -             -             -             -             -  15,  92 

Hilton,  -  -  -  -  -  ■  -68,117 

"  white  line"  of,       -             -             -                           -             -  67,  69 

Hippocrates,     --------  27 

treatment  of  fistula  by,        -             -                         -  -      64 

Horner,  sacculi  of,        -             -             -             -             -             -             -  4,  52 

Hypodermic  injection  of  piles,     -             -             -             ■             -  -      33 

accidents  from,                -----  34 

deaths  from,               -             -             -             -             -  -      34 


136  INDEX. 

PAGE 

Hypodermic  injection  of  piles,  Kelsey  on,    -            -             -             -  35 

rules  for, 

formulas  for  injections.       -  36,  126,  127 

Hyrtl,           ---------  2 

Imperforate  anus,         .         .         -         .         -          -  no 

Incised  wounds,         -             -             -                           -             -             -  118 

Infection,  avoidance  of,               ------  13 

Inflammation,  see  "  Proctitis,"        .  -  -  -  - 

Inguinal  glands,  enlargements  of,          -             -             -             -            -  12 

Inspection,  external,             ------  12 

Itinerant  "  rectal  specialists,"  methods  of,        -             -             -             -  33 

contracts  guaranteeing  cure,        -  122 

fissure,                -             -             -.             -  75 

fistula,        -             -             -             -  64 

haemorrhoids,                 -             -             -  33 

"pockets,"              -             -             -  55 

polypi,                -             -             -             -  88 

prolapse,                 -             -             .  86 


K. 


.ELSEY,  -  -  -  18,  19,  35,  78,  82,  101,  105,  115,  130 

Klein,  ....----  48 

Konig,     ■  -.-----  27,  28 


L. 


jANGENBECK,     -------  37 

Leclanche  battery  for  electric  lamp,      -             -             -             -             -  12 

Legendre,      --------  2 

Lemonnier,           --------  68 

Ligation  of  haemorrhoids,                 -----  27 

Ligature  for  fistula,         -------  64 

Light  for  examination,         ------  11 

Lisfranc,                --------  2 

Luschka,        --------  2 

Lymphatics  of  rectum,                 --_--.  7 

Magnesium  light,      -         -         -         -         -         -  ii 

Maisonneuve,       --------  68 

Malignant  tumors  of  rectum,           -----  101 

Malformations  of  rectum,           -             -             -             -             -             -  110 

Malgaigne,                 -------  2 

Matthews,             -             -             -             -             -              -             -        65,  66,  123 

Mechanical  injuries  of  rectum,       -----  118 

Mechanical  obstruction  of  rectum,         -----  90 


INDEX.  13 


PAGE 

Mikulicz,       --------  82 

Mitchell,                 ----...-  33 

MoUiere,        --------  68 

Morgagni,  columns  of,    -             -             -             -             -             -             -  3 

Muscles  of  anus,       -------  5 

Muscular  coat  of  rectum,             ------  3 


N: 


ERVE  stretching  for  pruritus,               -             -•             .             .  \\^ 

Nerves  of  rectum,             -------  7 

Neumann,        --------  43 

Nott,          -             -             -             -             -             -             -             -             -  41' 


0 


BSTRUCTION  of  rectum,              -----  90 

from  benign  tumors,               -  -             -             -       97 

from  displaced  organs,     -  -             -             -             98 

from  foreign  bodies,               -  -             -             -       96 

from  impacted  faeces,        -  -             -             -             99 

from  spasmodic  contraction,  -             -             -       99 

from  inflammatory  swelling,  -             -             -             98 


P. 


AGET,                .--.-.--  48 

Papillomata  of  anus,  -------  88 

Papillae  of  rectum,             -------  5 

Pare,  Ambrose,              -             -             .            -            -            -            -  67 

Paulus  ^gineta,         .         -             -             -            -            -            -             -  67 

Pediculi,             -------                113,  114 

Peritoneum,  danger  line  of,          -             -             -             -             -             -  2 

Piles,  see  "  haemorrhoids,"       ------ 

Pile,  "  sentinel,"     -             -             -             -             -             -             -             -  12 

Polypi,               --------  87 

rounded,     -             -             -             -             -             -             -             -  87 

villous,               .-,--.-  88 

treatment  of,          -             -             -             -            -            -            -  87 

itinerant  treatment  of,             V             -             -             -             -  88 

Proctitis,                 -             -             -             -             -             -             -             -  45 

causes  of,      -             -             -----  45 

diphtheritic,       -             -             -             -             -             -              -  46 

dysenteric,    -             -             -      .       -             -             -             -  47 

follicular,             -------  47 

gonorrhoeal,  -------  46 

syphilitic,            -             -             -             -             -             -             -  49 

tubercular,    -------  46 

hsemorrhoidal,    -             -             -             -             -             -             -  48 

symptoms  of,             ------  47 

treatment  of,      -             -             -             -             -             -             -  50 


138  INDEX. 

**  PAGE 

Prolapsus  of  rectum,        -------  gi 

of  all  the  coats,       ------  82 

of  mucous  membrane.              -             -             -             -             -  81 

cautery  in,                ------  85 

cautery,  potential,  in,               -----  86 

excision  of,              ------  84 

itinerant  treatment  of,          •   -             -             -             -             -  86 

Pruritus  ani,     -             ------             -  112 

causes  of,             -------  113 

treatment  of,               --.--.  113 


Q, 


LUAIN,     --------  2,  28 

Questions,  list  of,  for  examinations,  -  -      *      -  "  -  1*' 


R. 


.ECAMIER,        --------  68 

Rectum,  anatomy  of,    -             -----             -  1 

•     arteries   of,           -             -             -             -             -             -             -  6 

lymphatics  of,             -----             -  7 

mucous  membrane  of,     -             -             -             -             -             -  5 

muscular  layer  of,      -             -             -             -             -             -  .     3 

nerves  of,               -------  7 

papillcB  of,      ------             -  6 

peritoneal  coat  of,           -             -             -             -             -             -  2 

skin  about,     -------  5 

veins  of,    -             -                           -----  6 

Retention  of  urine.       -------  31 

Richet,         --------  2 

Roberts,              --------  2 

Rokitansky,             ----.-..  47 

Roser,                  --------  47 

"  Rorick  System,"              -             -             -             -            -             -             -  127 


s 


ABATIER,  --.-.-.  68 

Sacculi  Horneri,     -  -  -  -  -  -  -  4,  52 

Sappey,  --------  2 

Sanson,       ---------         2 

Sarcoma,  --------  105 

Sentinel  pile,  --------       12 

Sets  of  rectal  instruments,       ------  19 

Simon,         ---------     121 

Skin  about  anus,         -------  5 

Smith,  London,      -  -  -  -  -  -  -       37,  39,  40 

Smith,  Henry  H.,        -  -      '       -  -  -  -  -        53,  54 


INDEX.  139 

PAGE 

Sodomy,  infection  of  rectum  from,        -  -  -  -       46,  48,  76 

Sounds,  rectal,  -  -  -  -  -  -  -        14,  92 

Speculum,  rectal,  -  -  -  -  -  -  -       15 

Andrews'  deep,       ------  16 

curved,         -  -  -  -  -  -       16 

short,      ------  17 

Allingham's,  -  -  -  -  -  -       17 

four-bladed,  -  -  -  -  18 

Van  Buren's,  -  .  -  -  -  -       17 

Kelsey's,     -------  18 

Sphincter,  dilatation  of,    -  -  -  -  -  -  26,  29 

St.  Bartholomew's  Hospital,  .  .  _  -  -  loi 

St.  Lazarre,  "  ------       76 

St.  Mark's,  "  -  -  -  -  -  -      27,  57 

Syme,  ---------      68 

1  AYLOR,              -------_  48 

Trousseau,         --------  47 

Tuberculosis  of  rectum,     -             -             -             -             -             -             -  47 

Tumors  of  rectum,  benign,     ------  97 

colotomy  for,               _             -             -             -              .  i07 

^                              malignant,             -             -            -             .             .  \q\ 

sarcoma,         ------  105 

treatment  of,        -             -            -            -       104,  106,  107 


u> 


LCERS  of  rectum,  -             -             -             -             -             -  -      76 

causes  of,  -             -             -             -            -            -            -  76 

clinical  history  of,       -             -             -             -             -  -      76 

diagnosis  of,           ------  77 

chancroidal,  -             -             -             -             -             -  -       78 

syphilitic,                ------  77 

tubercular,  -             -             -             -             -             -  -      80 

treatment  of,          -             -    \         .             .             .             .  jg 

Urine,  retention  of,  -------      31 


V. 


AN  BUREN,  -  -  -  -  -  -     17,  28,  68,  124 

Vaseline,  aseptic  holder  for,  -  -  -  -  -  -      13 

Vegetations  on  anus,   -------  88 

Veins  of  rectum.     -  -  ------        6 

Velpeau,  --------  2 

Vernenil,     -  -  -  -  -  -  -  6,  26,  46,  105 

Vidal  de  Cassis,  -  -  -  -  -  -  -     86,  129 

Vulsellum  forceps  for  piles,  -  -  -  -  -  -      30 


140  INDEX. 


W- 


PAGE 

ALES,       -            -            ------  93 

Warts  on  anus,       -             -             -             -             -             -             -             -  88 

Weir,     ---------  41 

Whitehead's  excision  of  piles,       -             -             -             -             -             -  41 

Whitmire,          ....----  36 

Wounds  of  rectum,              -             -             -             -             -            ..             -  118 

incised,            .-.-.--  118 

after  lithotomy,  -------  118 

gunshot,          -             -             -             -             -             -             -  120 

lacerated,               -------  120 

punctured,      -------  120 

I  OUNT,  -            -             -             -             -             -             -             -             -  127 


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